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: 2024-12-10-59
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: 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: 4 Bags Comb. Agg (3/4", 1/2", 3/8", rockdust)
A brief description of the sample: 3/4" RWMA-G-SP 0.4% EVO
From where was the sample collected: Manufacturer
Laboratory sample identification: 0691G-24
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: All American Asphalt Corona
Source Identification (SMARA, name of Pit or Job Site): 91-33-0005
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: 3/4" RWMA-G-SP 0.4% EVO
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number: 108835
Lot number:
Sublot number:
Aggregate Mix Number:
