Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000611 DEA: 120R32U4 EFIS: 1222000054
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-55-0.2/R17.8
Work Description: COLD PLANE, PLACE RHMA, REPLACE CB, SIGNS AND MODIFY LIGHTING SYSTEM.
Location Description: ORANGE COUNTY FROM 0.1 MILE SOUTH OF ROUTE 55/1 SEPARATION IN NEWPORT BEACH TO ROUTE 55/91 SEPARATION IN ANAHEIM
Contractor Name: R.J. NOBLE COMPANY
Contractor Address: 15505 East Lincoln Avenue, Orange, CA 92865
Resident Engineer: Tyrone Taylor Structure Rep.: Matthew Chang
DIME Sample ID: 2025-09-05-44
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: 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: 1BAG CRM RUBBER
A brief description of the sample: 1BAG OF CRM RUBBER
From where was the sample collected: Manufacturer
Laboratory sample identification: 05540-25
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: WORLD OIL, M.M-EAGLE VALLEY
