Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994586 DEA: 081C08U4 EFIS: 0822000142
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-10-R134.0/R156.5
Work Description: PLACE HMA (TYPE A), JPCP, IMPORTED BORROW, ROADWAY EXCAVATION & CL2 AB
Location Description: RIVERSIDE COUNTY FROM 1.1 MILES WEST OF WILEY WELL ROAD OVERCROSSING TO CALIFORNIA/ARIZONA STATE LINE
Contractor Name: FISHER SAND & GRAVEL CO.
Contractor Address: 19062 San Jose Avenue, LA Puente, CA 91748
Resident Engineer: Ryan Espoy (cc on Reports) Structure Rep.: Tim Flores
DIME Sample ID: 2025-10-07-44
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: Aggregate
Sample Taken Date: 10/07/2025
Date that the sample was received by the laboratory/organization performing the testing: 10/13/2025
The quantity of what the sample constitutes: 8 Bags Virgin Agg, 2 bags comb LT Agg, 1 Bag Crumb Rubber Scrap, 1 bag Hi-Nat
A brief description of the sample: PSUE 1/2" RHMA-G-SP 1.0% LSM
From where was the sample collected: Manufacturer
Laboratory sample identification: 0642G-25
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CRM of Amer, HF Sinclair, LHoist, Fisher Sand and Gravel
Source Identification (SMARA, name of Pit or Job Site): Fisher Sand and Gravel Company
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 at FISHER SAND AND GRAVEL TEMPE AZ
Where the material sample would have been placed if not sampled: Asphalt Paving
Primary Aggregate Nominal Size: 1/2 inch
The concrete mix design number: 530AKR
Lot number:
Sublot number:
Aggregate Mix Number:
