Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994190 DEA: 07341604 EFIS: 0717000194
QA Service Level: 1
DIST-CO-RTE-PM: 07-VEN-118-13.3/15.6
Work Description: CONSTRUCT NEW MODULAR OFFICE FACILITY.
Location Description: VENTURA COUNTY IN AND NEAR MOORPARK FROM 0.1 MILE EAST OF BALCOM CANYON ROAD TO 0.1 MILE WEST OF MONTAIR DRIVE
Contractor Name: 3SIXTY INNOVATION INC.
Contractor Address: 3555 ROSECRANS ST 114-110, SAN DIEGO CA 92110
Resident Engineer: Seyedomid Barzanji Structure Rep.: Unknown
DIME Sample ID: 2026-05-08-36
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: 05/08/2026
Date that the sample was received by the laboratory/organization performing the testing: 05/13/2026
The quantity of what the sample constitutes: 4 bags of Cold feed, 2 bags of RAP
A brief description of the sample: PSU 3/4" HMA-A-SP R25
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Granite - Santa Paula
Source Identification (SMARA, name of Pit or Job Site): 91-19-0046
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 Plant
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
