Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001225 DEA: 070Y1604 EFIS: 0724000137
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-210-R9.9/R22.5
Work Description: SLAB REPLACEMENT, SLURRY SEAL, AND DIGOUTS.
Location Description: LOS ANGELES COUNTY, IN LOS ANGELES, LA CANADA FLINTRIDGE, GLENDALE, AND PASADENA FROM BIG TUJUNGA WASH BRIDGE TO ARROYO BOULEVARD OVERCROSSING
Contractor Name: RV CONCRETE, INC.
Contractor Address: Unknown
Resident Engineer: Bill Tran Structure Rep.: Unknown
DIME Sample ID: 2025-10-06-33
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: 10/06/2025
Date that the sample was received by the laboratory/organization performing the testing: 10/09/2025
The quantity of what the sample constitutes: 1 Bag Hi-Nat
A brief description of the sample: PSUE 1/2" RHMA-G-SP 1.0% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0638G-25
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: AAA-Corona/ Irwindale/ SJR/ Rohm & Haas (Morelife 5000)
