Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000286 DEA: 070W7004 EFIS: 0723000032
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-405-44.7/48.64
Work Description: INDIVIDUAL SLAB REPLACEMENT (RSC), & GRIND EXIST CONC PAVEMENT.
Location Description: LOS ANGELES COUNTY IN LOS ANGELES FROM NORDHOFF STREET UNDERCROSSING TO ROUTE 5/405 SEPARATION
Contractor Name: Interstate Civil Construction
Contractor Address: PO Box 2819, Wrightwood, CA 92397
Resident Engineer: ALI MOHSENZADEH Structure Rep.: Unknown
DIME Sample ID: 2025-03-24-46
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: Asphalt Binder
Sample Taken Date: 03/24/2025
Date that the sample was received by the laboratory/organization performing the testing: 04/03/2025
The quantity of what the sample constitutes: 1can
A brief description of the sample: JMF verification sample
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan Irwindale
Performance Grade: PG 64-16
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: San Joaquin Refinery - Bakersfield CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
