Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000669 DEA: 072XA704 EFIS: 0725000022
QA Service Level: 1
DIST-CO-RTE-PM: 07---
Work Description:
Location Description:
Contractor Name: RJ Noble Company
Contractor Address: 15505 E. Lincoln Ave, Orange, CA 92865
Resident Engineer: Vanna Nguyen Structure Rep.: Unknown
DIME Sample ID: 2025-04-07-24
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: Production Start-Up
Type of Material: Hot Mix Asphalt
Sample Taken Date: 04/07/2025
Date that the sample was received by the laboratory/organization performing the testing: 04/10/2025
The quantity of what the sample constitutes: 20 BX HMA 4 QT PG58-22 1 QT EVO 4 BGS CMB AGG 1 BG RP
A brief description of the sample: 3/4" WMA A SP R25 0.25% EVO
From where was the sample collected: Manufacturer
Laboratory sample identification: 0207A-25
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: RJ Noble Orange
