Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001850 DEA: 081T3304 EFIS: 0826000040
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-38-
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2025-12-20-3
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: Aggregate
Sample Taken Date: 12/20/2025
Date that the sample was received by the laboratory/organization performing the testing: 12/23/2025
The quantity of what the sample constitutes: 3 bags comb agg, 1 bag EA RAP (Coarse and Fine)
A brief description of the sample: PSUE 3/4" HMA-A- SP R20% EVO 0.5%
From where was the sample collected: Manufacturer
Laboratory sample identification: 0703A-25
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Valero, Ingevity, Cemex Lytle Creek
Source Identification (SMARA, name of Pit or Job Site): 91-36-0040
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 Matich Lytle Creek Plant
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: B6Z
Lot number:
Sublot number:
Aggregate Mix Number:
