Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000851 DEA: 07351704 EFIS: 0718000204
QA Service Level: 1
DIST-CO-RTE-PM: 07-VEN-118,118-15.6/R17.9
Work Description: COLD PLANE AC PAVEMENT AND PLACE RUBBERIZED HMA.
Location Description: VENTURA COUNTY IN MOORPARK AT VARIOUS LOCATIONS
Contractor Name: C. A. RASMUSSEN, INC.
Contractor Address: Unknown
Resident Engineer: Pantaleon Rivera Structure Rep.: Unknown
DIME Sample ID: 2026-03-23-50
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: 03/23/2026
Date that the sample was received by the laboratory/organization performing the testing: 04/06/2026
The quantity of what the sample constitutes: 4 bags comb agg, 1 bag EA CRM (Scrap & Hi-Nat)
A brief description of the sample: PSUE 3/4" RHMA-G-SP 0.5% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0171G-26
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Ingevity/ Valero/ Fish Canyon Irwindale
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 Sun Valley 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: 226108M SVA VLO
Lot number:
Sublot number:
Aggregate Mix Number:
