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: 2026-03-20-44
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: 03/20/2026
Date that the sample was received by the laboratory/organization performing the testing: 04/01/2026
The quantity of what the sample constitutes: 4 bags comb agg, 4 bags comb RAP
A brief description of the sample: JMF 3/4" HMA-A-SP RAP 20% LAS 0.5%
From where was the sample collected: Manufacturer
Laboratory sample identification: 0165A-26
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Evotherm - Valero - Cemex LC - Matich LCHP
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: B6Z3
Lot number:
Sublot number:
Aggregate Mix Number:
