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: 2026-03-10-28
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: 03/10/2026
Date that the sample was received by the laboratory/organization performing the testing: 03/11/2026
The quantity of what the sample constitutes: 5 Bags of Comb. Agg. 2 Bags of Comb. RAP
A brief description of the sample: JMF 3/4" WMA A SP RAP 22% LAS .25%
From where was the sample collected: Manufacturer
Laboratory sample identification: 0146A-26
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan Corona
Source Identification (SMARA, name of Pit or Job Site): 91-33-0027
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 and chute
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number: Mix 220200W
Lot number:
Sublot number:
Aggregate Mix Number:
