Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214344 DEA: 120P42U4 EFIS: 1216000097
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-5,22,55,57,91,405-Var
Work Description: Upgrade and install Intelligent Transportation System (ITS) elements
Location Description: ORANGE COUNTY
Contractor Name: ILB Electric
Contractor Address: 3955 Temescal Canyon Rd., Corona, CA 92883
Resident Engineer: Bibars Kattao Structure Rep.: Bijan Ronagh-Langroodi
DIME Sample ID: 2023-12-08-21
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: 12/08/2023
Date that the sample was received by the laboratory/organization performing the testing: 12/12/2023
The quantity of what the sample constitutes: 80 TONS
A brief description of the sample: 3/4" HMA-A
From where was the sample collected: Manufacturer
Laboratory sample identification: 23-1330
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: VULCAN - CORONA
