Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995228 DEA: 07347904 EFIS: 0718000123
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-405-31.2/41.4
Work Description: COLD PLANE, PLACE HMA, RHMA, JPCP, ISR, & REPLACE BRIDGE SLABS.
Location Description: LOS ANGELES FROM WILSHIRE BOULEVARD UNDERCROSSING TO VICTORY BOULEVARD UNDERCROSSING
Contractor Name: RASMUSSEN/VANGUARD
Contractor Address: 28548 Livingston Ave, Valencia , CA,91355-4171
Resident Engineer: Ridwan Salman Structure Rep.: Gon Choi
DIME Sample ID: 2026-03-22-12
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: 03/22/2026
Date that the sample was received by the laboratory/organization performing the testing: 04/01/2026
The quantity of what the sample constitutes: 1 bag Crumb Rubber Scrap Tire
A brief description of the sample: 1 bag CRM Scrap
From where was the sample collected: Manufacturer
Laboratory sample identification: 0164G-26
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Ingevity, Valero, Fish Canyon Irwindale
