Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000501 DEA: 081J6104 EFIS: 0818000102
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-215-40.5/42.7
Work Description: INDIVIDUAL SLAB REPLACEMENT (RSC), RHMA, AND REPLACE BASE.
Location Description: RIVERSIDE COUNTY IN RIVERSIDE FROM 0.8 MILE SOUTH OF ROUTE 60/91 SEPARATION TO 0.4 MILE SOUTH OF MARTIN LUTHER KING BOULEVARD UNDERCROSSING
Contractor Name: FBD VANGUARD CONSTRUCTION, INC.
Contractor Address: 550 Greenville Rd., Livermore, CA
Resident Engineer: Mahfual Alam Structure Rep.: Unknown
DIME Sample ID: 2026-05-07-29
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: 05/07/2026
Date that the sample was received by the laboratory/organization performing the testing: 05/11/2026
The quantity of what the sample constitutes: 4 bags comb agg, 1 bag EA RAP (Coarse and Fine)
A brief description of the sample: PSUE 3/4" RHMA-G-SP 0.25% EVO
From where was the sample collected: Manufacturer
Laboratory sample identification: 0221G-26
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: San Juaquin Refinery, CRM, Ingevity, Martin Marietta, Mayhew
Source Identification (SMARA, name of Pit or Job Site): 91-33-0084
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 RJ Noble Corona 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: 49003ARSPWEC
Lot number:
Sublot number:
Aggregate Mix Number:
