Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214697 DEA: 07307104 EFIS: 0714000213
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-101-32.8
Work Description: CONSTRUCT BRIDGE.
Location Description: LOS ANGELES COUNTY IN AND NEAR AGOURA HILLS FROM 0.1 MILE WEST OF LIBERTY CANYON ROAD UNDERCROSSING TO 0.6 MILE EAST OF PALO COMADO OVERCROSSING
Contractor Name: CA Rasmussen
Contractor Address: 28548 LIVINGSTON AVENUE, VALENICA CA 91355
Resident Engineer: Sam Toutounchian Structure Rep.: Darwin Vargas
DIME Sample ID: 2024-09-16-58
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Verification
Type of Material: Aggregate
Sample Taken Date: 09/16/2024
Date that the sample was received by the laboratory/organization performing the testing: 09/18/2024
The quantity of what the sample constitutes: 4 Bags of comb. agg., 2 bags of RAP
A brief description of the sample: JMF 3/4" WMA-A-SP R25 0.50% EVO
From where was the sample collected: Manufacturer
Laboratory sample identification: 0483A-24
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Ingevity/ Valero/ Fish Canyon Irwindale/ Vulcan Sun Valley
Source Identification (SMARA, name of Pit or Job Site): 91-19-0035
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: Belt Cut at Vulcan Sun Valley Plant
Where the material sample would have been placed if not sampled: Asphalt Paving
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number: 220200W SVA VLO
Lot number:
Sublot number:
Aggregate Mix Number:
