Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000903 DEA: 081M0404 EFIS: 0821000091
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-40-R140.0/R142.2
Work Description: COLD PLANE AC & RHMA, VEGETATION CONTROL (MINOR CONC), MGS, AND HTCB.
Location Description: SAN BERNARDINO COUNTY IN NEEDLES FROM FOX WASH OVERFLOW TO L STREET UNDERCROSSING
Contractor Name: INTERSTATE CIVIL CONSTRUCTION
Contractor Address: Unknown
Resident Engineer: Anthony Doan Structure Rep.: Jegbefume Adodo
DIME Sample ID: 2026-04-20-22
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: 04/20/2026
Date that the sample was received by the laboratory/organization performing the testing: 04/22/2026
The quantity of what the sample constitutes: 16 bags Lime Treated Agg
A brief description of the sample: PSUE 1/2" WMA-O PG70-10 LSM
From where was the sample collected: Manufacturer
Laboratory sample identification: 0200O-26
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: SJR, LHoist, Ingevity, West Coast Agg
Source Identification (SMARA, name of Pit or Job Site): 91-33-0072
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 Granite Indio Plant
Where the material sample would have been placed if not sampled: Asphalt Paving
Primary Aggregate Nominal Size: 1/2 inch
The concrete mix design number: 14987
Lot number:
Sublot number:
Aggregate Mix Number:
