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: 2024-11-08-39
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: Crumb Rubber Modifier
Sample Taken Date: 11/08/2024
Date that the sample was received by the laboratory/organization performing the testing: 11/13/2024
The quantity of what the sample constitutes: 1 Bag of CRM Scrap
A brief description of the sample: JMF 3/4" RHMA-G-SP 0.5% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0621G-24
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Ingevity, Valero, Fish Canyon Irwindale
