Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001960 DEA: 081J65U4 EFIS: 0824000091
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-10-0.0/R8.2
Work Description: HMA, RHMA, JPCP, JPCP(RSC), and individual slab replacement (RSC).
Location Description:
Contractor Name: Flatiron Dragados
Contractor Address: 12121 scripps Summit Drive, suite 400, Sandeigo, CA 92131
Resident Engineer: Sadique Hossain Structure Rep.: Unknown
DIME Sample ID: 2026-05-18-29
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: 05/18/2026
Date that the sample was received by the laboratory/organization performing the testing: 05/19/2026
The quantity of what the sample constitutes: PSU 2 bags of Combined Agg, I bag of Fine RAP, 1 bag of Coarse RAP
A brief description of the sample: 3/4" HMA-A-SP R15 NO LAS
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: All American Asphalt Corona
Source Identification (SMARA, name of Pit or Job Site): 91-33-0005
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: 105793
Lot number:
Sublot number:
Aggregate Mix Number:
