Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213750 DEA: 120K0224 EFIS: 1214000097
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-5-14.5/17.1
Work Description: South County Improvement Project (Phase 2 - Oso/Alicia) CONST BRIDGES, RW, SW, HMA PVMT, JPCP, DRAINAGE, AND ELECT SYSTEMS.
Location Description: ORANGE COUNTY IN MISSION VIEJO AND LAGUNA HILLS FROM 0.7 MILE SOUTH OF OSO PARKWAY OVERCROSSING TO 0.3 MILE SOUTH OF ALICIA PARKWAY OVERCROSSING
Contractor Name: Flatiron West, Inc
Contractor Address: 1770 La Costa Meadows Drive, San Marcos, California 92078
Resident Engineer: Steven Kim Structure Rep.: Sara Soleimani
DIME Sample ID: 2023-09-30-1
TL Number from the TL Form:
Sample Submitted By Organization: CT D12 - Huntington Beach Field Laboratory
Sample Organization Contact: 9492798846
Type of Sample: Quality Assurance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 09/30/2023
Date that the sample was received by the laboratory/organization performing the testing: 10/02/2023
The quantity of what the sample constitutes: 1400 TONS
A brief description of the sample: 3/4" HMA-A
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: 23-1034
