Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213404 DEA: 120Q3404 EFIS: 1216000130 Permit Numbers: 1217NMC0723 1218NDP0423 1218NRT0056
QA Service Level: 2
DIST-CO-RTE-PM: 12-ORA-241-13.1/16.7
Work Description: Construct the Oso PWY bridge and extend SR-241 to connect to Los Patrones PKW. in the County of Orange. Two lanes will be constructed of HMA in each direction on SR-241. Oso Parkway N/B on-ramp and S/B off-ramp gores will be modified to connect to new mainline pavement. improve new overhead signs,
Location Description: OSO PARKWAY INTERCHANGE, COUNTY OF ORANGE
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Kami Fallah Structure Rep.: Sara Solemani
DIME Sample ID: 2023-08-31-27
TL Number from the TL Form:
Sample Submitted By Organization: CT D09 - Bishop Field Laboratory
Sample Organization Contact: (760) 872-5211
Type of Sample: Verification
Type of Material: Aggregate
Sample Taken Date: 08/31/2023
Date that the sample was received by the laboratory/organization performing the testing: 08/31/2023
The quantity of what the sample constitutes: 1 Bag of Coldfeed & 1 Bag of RAP
A brief description of the sample: 3/4" HMA Coldfeed & RAP
From where was the sample collected: Source
Laboratory sample identification: JMF 2
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Fisher Sand & Gravel
Source Identification (SMARA, name of Pit or Job Site): 00-00-0000
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
The plant number:
A detailed description of where the material sample was collected: Sampled from Belt Cut at Hot Plant
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
