Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 66667 DEA: JMFPP EFIS: 0019000043
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for submitting Sample information for JMF Prequalification Program.
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2025-11-05-38
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: Hot Mix Asphalt
Sample Taken Date: 11/05/2025
Date that the sample was received by the laboratory/organization performing the testing: 11/06/2025
The quantity of what the sample constitutes: 24 BX RHMA 2 QT PG64-16 6 QT RBR BLND 1 QT LAS 12 BG CMB AGG
A brief description of the sample: 1/2" RHMAG SP 1.0% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0670G-25
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: AAA Irwindale
