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: 2025-11-07-3
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: 11/07/2025
Date that the sample was received by the laboratory/organization performing the testing: 11/07/2025
The quantity of what the sample constitutes: 1 Bag of Hi-nut
A brief description of the sample: Scrap
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: AAA-Irwindale
