Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000665 DEA: 081K4004 EFIS: 0819000031
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-15-3.5/6.8
Work Description: HMA (TYPE A), RDWY EXC, STR CONC RET WALL, RUBBERIZED HMA (OGFC).
Location Description: TEMECULA FROM 0.1 MI NORTH OF TEMECULA PARKWAY TO 0.2 MI NORTH OF WINCHESTER ROAD
Contractor Name: BEADOR CONSTRUCTION COMPANY, INC.
Contractor Address: 2900 Bristol Street, Suite D204, Costa Mesa, CA 92626
Resident Engineer: Denise Sostrom Structure Rep.: Gizachew Abayneh
DIME Sample ID: 2025-09-16-39
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: 09/16/2025
Date that the sample was received by the laboratory/organization performing the testing: 09/17/2025
The quantity of what the sample constitutes: 1Bag Hi-Nat
A brief description of the sample: Hi-Nat
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: World oil, SJR, CRM, M.M. (91-33-0014)
