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: 2025-09-23-40
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: 09/23/2025
Date that the sample was received by the laboratory/organization performing the testing: 09/25/2025
The quantity of what the sample constitutes: 1 Bag of Crum Rubber
A brief description of the sample: JMF Verification, 1/2" RHMA G SP .4% EVO LSM 1.o%
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Blue Diamond-Victorville
