Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000665 DEA: 081K4004 EFIS: 0819000031
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-15-3.5/6.8
Work Description: HMA (TYPE A), RDWY EXC, STR CONC RET WALL, RUBBERIZED HMA (OGFC).
Location Description: TEMECULA FROM 0.1 MI NORTH OF TEMECULA PARKWAY TO 0.2 MI NORTH OF WINCHESTER ROAD
Contractor Name: BEADOR CONSTRUCTION COMPANY, INC.
Contractor Address: 2900 Bristol Street, Suite D204, Costa Mesa, CA 92626
Resident Engineer: Denise Sostrom Structure Rep.: Gizachew Abayneh
DIME Sample ID: 2025-11-07-30
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: 11/07/2025
Date that the sample was received by the laboratory/organization performing the testing: 11/13/2025
The quantity of what the sample constitutes: 24 BX HMA 4 BG CMB AGG 4 BG RAP 4 QT PG58-22 1 QT EVO
A brief description of the sample: 3/4" HMA A SP R25 .25% EVO
From where was the sample collected: Manufacturer
Laboratory sample identification: 0676A-25
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: RJ Noble Corona
