Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993387 DEA: 07323404 EFIS: 0716000064
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-R59.5/R67.9
Work Description: PLACE CULVERT, REPLACE DRAINAGE SYSTEM, RECONST ROADWAY & EMBANKMENT.
Location Description: LOS ANGELES COUNTY AT VARIOUS LOCATIONS FROM LAKE HUGHES ROAD UNDERCROSSING TO 1.9 MILES NORTH OF TEMPLIN HIGHWAY UNDERCROSSING
Contractor Name: SECURITY PAVING COMPANY INC
Contractor Address: 13170 TELEFAIR AVE, SYLMAR, CA 91342
Resident Engineer: Oscar Osorio Structure Rep.: Chanh Tong
DIME Sample ID: 2024-09-16-62
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 FINE Rap
A brief description of the sample: JMF 3/4'' WMA A SP R25 .50% EVO
From where was the sample collected: Manufacturer
Laboratory sample identification: 0482A-24
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: INGEVITY, SJR, 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 SJR
Lot number:
Sublot number:
Aggregate Mix Number:
