Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000606 DEA: 081J3004 EFIS: 0818000016
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-18-90.9/R96.6
Work Description: HMA (TYPE A), MOD SIGNAL & LTG SYSTEMS, & COLD PLANE AC PVMT.
Location Description: SAN BERNARDINO COUNTY IN AND NEAR VICTORVILLE FROM APPLE VALLEY INN ROAD TO ROUTE 15/18 SEPARATION
Contractor Name: SULLY-MILLER CONTRACTING COMPANY
Contractor Address: 135 S STATE COLLEGE BLVD #400, BREA CA 92821
Resident Engineer: Alfonso Gonzalez Structure Rep.: Unknown
DIME Sample ID: 2025-03-25-34
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: 03/25/2025
Date that the sample was received by the laboratory/organization performing the testing: 04/02/2025
The quantity of what the sample constitutes: 24 BX HMA 4 BG CMB AGG 2 BG RAP 4 QT PG70-10 2 QT LAS
A brief description of the sample: 1/2" HMA A SP .3% EVO
From where was the sample collected: Manufacturer
Laboratory sample identification: 0189A-25
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Blue Diamond-Victorville
