Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000101 DEA: 081J2904 EFIS: 0818000015
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-215-25.0/R31.2
Work Description: RHMA, HMA, REPLACE AC SURFACING, AND COLD PLANE AC PVMT.
Location Description: RIVERSIDE COUNTY IN AND NEAR PERRIS FROM 0.1 MILE SOUTH OF SAN JACINTO RIVER BRIDGE TO 0.3 MILE NORTH OF RAMONA EXPRESSWAY
Contractor Name: COFFMAN SPECIALTIES, INC.
Contractor Address: 9685 Via Excelencia, Suite 200, San Diego, CA 92126
Resident Engineer: Mohamad Alsheikh Structure Rep.: Unknown
DIME Sample ID: 2024-09-19-29
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: Hot Mix Asphalt
Sample Taken Date: 09/19/2024
Date that the sample was received by the laboratory/organization performing the testing: 09/20/2024
The quantity of what the sample constitutes: 36 BX HMA 4 QT PG64-16 2 QT LAS 5 BGS CMB AG 3 BGS RAP
A brief description of the sample: 3/8" HMA A SP R25 .5% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0490A-24
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Martin Marietta Lake Elsinore
