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: 2025-03-24-47
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: 03/24/2025
Date that the sample was received by the laboratory/organization performing the testing: 04/03/2025
The quantity of what the sample constitutes: 24 BX HMA 4 BG CMB AG 4 QT RBR BLND 2 QT LAS 1 QT EXT OIL 2 QT PG64-16 1 BG HN 1 BG RBR CRM
A brief description of the sample: 3/4" RHMA G SP 0.5% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0191G-25
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan Irwindale
