Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995489 DEA: 07344204 EFIS: 0718000046
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5,710-23.2/36.3,21.9
Work Description: CONSTRUCT GSRDS, MVPS, AND BIOSWALES.
Location Description: LOS ANGELES COUNTY AT VARIOUS LOCATIONS
Contractor Name: POWELL CONSTRUCTORS, INC.
Contractor Address: Unknown
Resident Engineer: Danglong Tran Structure Rep.: Gon Choi
DIME Sample ID: 2025-12-17-16
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: 12/17/2025
Date that the sample was received by the laboratory/organization performing the testing: 12/19/2025
The quantity of what the sample constitutes: 6 bags of comb agg, 2 bags RAP
A brief description of the sample: PSUE 3/4" WMA-A-SP R25 0.50% EVO
From where was the sample collected: Manufacturer
Laboratory sample identification: 0699A-25
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Ingevity, Valero, Fish Canyon Irwindale, Vulcan Sun Valley
Source Identification (SMARA, name of Pit or Job Site): 91-19-0035
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 Vulcan Materials Sun Valley
Where the material sample would have been placed if not sampled: Asphalt Paving
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number: 220200W SVA VLO
Lot number:
Sublot number:
Aggregate Mix Number:
