Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001001 DEA: 081N7704 EFIS: 0823000047
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-173-L0.0/L7.7
Work Description: COLD PLANE AC PVMT, HMA (TYPE A), AND REPLACE AC SURFACING.
Location Description: SAN BERNARDINO COUNTY IN HESPERIA FROM ROUTE 138 TO 0.5 MILE EAST OF ARROWHEAD LAKE ROAD
Contractor Name: CALMEX ENGINEERING, INC.
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2025-07-10-75
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: Aggregate
Sample Taken Date: 07/10/2025
Date that the sample was received by the laboratory/organization performing the testing: 07/22/2025
The quantity of what the sample constitutes: 2BAGS EA BIN SIZE,(1/2,3/8,MINUS#4),2BAGS RAP
A brief description of the sample: JMF Verification (T30)
From where was the sample collected: Manufacturer
Laboratory sample identification: 0454A-25
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Ingevity,Valero,Cal portland,Aggcon
Source Identification (SMARA, name of Pit or Job Site): 91-36-0022/91-36-0046
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
The plant number:
A detailed description of where the material sample was collected: BELT CUT VULCAN ORO GRANDE
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1/2 inch
The concrete mix design number: 320311W ORO VAL
Lot number:
Sublot number:
Aggregate Mix Number:
