Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001153 DEA: 081L3104 EFIS: 0820000020
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-74-11.8/17.3
Work Description: RHMA (GAP GRADED), REPLACE AC SURF, AND COLD PLANE AC PVMT.
Location Description: RIVERSIDE COUNTY IN LAKE ELSINORE FROM GRAND AVENUE TO ROUTE 15/74 SEPARATION
Contractor Name: R.J. NOBLE COMPANY
Contractor Address: Unknown
Resident Engineer: Xavier Avila Structure Rep.: Unknown
DIME Sample ID: 2026-04-08-40
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: 04/08/2026
Date that the sample was received by the laboratory/organization performing the testing: 04/13/2026
The quantity of what the sample constitutes: 1 bag crumb rubber
A brief description of the sample: 1 Bag Crumb Rubber Scrap Tire
From where was the sample collected: Manufacturer
Laboratory sample identification: 0188G-26
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Ingevity, World Oil, Chandler's Agg, CRM Co
