Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000903 DEA: 081M0404 EFIS: 0821000091
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-40-R140.0/R142.2
Work Description: COLD PLANE AC & RHMA, VEGETATION CONTROL (MINOR CONC), MGS, AND HTCB.
Location Description: SAN BERNARDINO COUNTY IN NEEDLES FROM FOX WASH OVERFLOW TO L STREET UNDERCROSSING
Contractor Name: INTERSTATE CIVIL CONSTRUCTION
Contractor Address: Unknown
Resident Engineer: Anthony Doan Structure Rep.: Jegbefume Adodo
DIME Sample ID: 2025-09-05-42
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: 09/05/2025
Date that the sample was received by the laboratory/organization performing the testing: 09/11/2025
The quantity of what the sample constitutes: 6 BAGS CMB LT AGG, 8 QTS PG70-10, 1 QT EVO
A brief description of the sample: 1/2" WMA - O PG70-10 LM
From where was the sample collected: Manufacturer
Laboratory sample identification: 0553O-25
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Granite Indio
