Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212503 DEA: 081C0804 EFIS: 0812000286
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-60-R0.0/R1.8
Work Description:
Location Description:
Contractor Name: Maneri Traffic Control, Inc.
Contractor Address: 47423 Rainbow Canyon, Temecula, CA 92592
Resident Engineer: David Benson Structure Rep.: Unknown
DIME Sample ID: 2025-10-07-45
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: 10/07/2025
Date that the sample was received by the laboratory/organization performing the testing: 10/13/2025
The quantity of what the sample constitutes: 1 bag CRM RBR
A brief description of the sample: 1 BAG OF SCRAP
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
