Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000777 DEA: 07370404 EFIS: 0720000128
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-R59.5/R73.7
Work Description: COLD PLANE AC PAVEMENT, PLACE HOT MIX ASPHALT AND INSTALL MGS.
Location Description: LOS ANGELES COUNTY FROM LAKE HUGHES ROAD UNDERCROSSING TO 0.7 MILE SOUTH OF VISTA DEL LAGO ROAD OVERCROSSING.
Contractor Name: GRIFFITH COMPANY
Contractor Address: 1128 Carrier Parkway Avenue, Bakersfield, CA 93308
Resident Engineer: Ridwan Salman Structure Rep.: Unknown
DIME Sample ID: 2025-07-17-53
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: Crumb Rubber Modifier
Sample Taken Date: 07/17/2025
Date that the sample was received by the laboratory/organization performing the testing: 07/21/2025
The quantity of what the sample constitutes: 1 CAN CRB RBR SCRAP TIRE
A brief description of the sample: 1 CAN OF SCRAP TIRE
From where was the sample collected: Manufacturer
Laboratory sample identification: 0453G-25
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: SJR, CRM CO, GRIFFITH, LHOIST NORTH AMERICA
