Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000164 DEA: 081N7804 EFIS: 0823000048
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-40-R129.8/R135.9
Work Description: RUBBERIZED HMA, COLD PLANE AC PVMT AND REPLACE AC SURFACING.
Location Description: SAN BERNARDINO COUNTY FROM 2.9 MILES WEST TO 3.2 MILES EAST OF ROUTE 95
Contractor Name: SULLY-MILLER CONTRACTING COMPANY
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2025-09-23-39
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: Aggregate
Sample Taken Date: 09/23/2025
Date that the sample was received by the laboratory/organization performing the testing: 09/25/2025
The quantity of what the sample constitutes: 3 Bags of Combined LT Agg, 8 Bags of Virgin Agg, 1 Bag EA Hi-Nat & Crum Rubber
A brief description of the sample: JMF Verification, 1/2" RHMA G SP .4% EVO. LSM 1.0%
From where was the sample collected: Manufacturer
Laboratory sample identification: 0602G-25
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Blue Diamond-Victorville
Source Identification (SMARA, name of Pit or Job Site): 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, Blue Diamond - Victorville
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1/2 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number: 300191 LSM WMA
