Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994586 DEA: 081C08U4 EFIS: 0822000142
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-10-R134.0/R156.5
Work Description: PLACE HMA (TYPE A), JPCP, IMPORTED BORROW, ROADWAY EXCAVATION & CL2 AB
Location Description: RIVERSIDE COUNTY FROM 1.1 MILES WEST OF WILEY WELL ROAD OVERCROSSING TO CALIFORNIA/ARIZONA STATE LINE
Contractor Name: FISHER SAND & GRAVEL CO.
Contractor Address: 19062 San Jose Avenue, LA Puente, CA 91748
Resident Engineer: Ryan Espoy (cc on Reports) Structure Rep.: Tim Flores
DIME Sample ID: 2024-11-18-32
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: Production Start-Up
Type of Material: Aggregate
Sample Taken Date: 11/18/2024
Date that the sample was received by the laboratory/organization performing the testing: 11/25/2024
The quantity of what the sample constitutes: 2 BAGS OF COMB LT AGGS(3/4,1/2,3/8, WASHED MA SAND)1 BAG C, RAP,1 BAG F,RAPM 2BAG EA OF VIRGIN AGG
A brief description of the sample: 3/4" HMA-A-SP-R24 1.0% LSM
From where was the sample collected: Manufacturer
Laboratory sample identification: 0643A-24
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Fisher Sand and Gravel-Tempe
Source Identification (SMARA, name of Pit or Job Site): EHRENBERG PIT CM203
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: EHRENBERG PIT/HOLLY FRONTIER/LHOIST/ PROJECT ROADWAY
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number: CA125MA
Lot number:
Sublot number:
Aggregate Mix Number:
