Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994121 DEA: 120P68U4 EFIS: 1218000105
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-1-13.0/33.7
Work Description: COLD PLANE, PLACE RHMA AND MODIFY CURB RAMPS AND ELECTRICAL SYSTEMS.
Location Description: ORANGE COUNTY AT VARIOUS LOCATIONS FROM CRYSTAL HEIGHTS DRIVE TO LOS ANGELES/ORANGE COUNTY LINE
Contractor Name: CHUMO CONSTRUCTION INC.
Contractor Address: 4949 2nd St., Fallbrook, CA 92028
Resident Engineer: Christopher Blanco Structure Rep.: Vian Ghazi
DIME Sample ID: 2024-12-10-58
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: Crumb Rubber Modifier
Sample Taken Date: 12/10/2024
Date that the sample was received by the laboratory/organization performing the testing: 12/23/2024
The quantity of what the sample constitutes: 1 Bag Hi Nat
A brief description of the sample: 3/4" RWMA-G-SP 0.4% EVO
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: All American Asphalt Corona
