Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000481 DEA: 081C07U4 EFIS: 0824000168
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-74-27.5/34.3
Work Description: RUBBERIZED HMA, FIBER OPTIC CABLE SYSTEMS, AND COLD PLANE AC PAVEMENT.
Location Description: RIVERSIDE COUNTY AT AND NEAR ROMOLAND AND HOMELAND FROM BONNIE DRIVE TO WINCHESTER ROAD
Contractor Name: GRIFFITH COMPANY
Contractor Address: 12200 Bloomfield Avenue, Santa Fe Springs, CA 90670
Resident Engineer: Omar Sanchez Structure Rep.: Unknown
DIME Sample ID: 2026-06-10-34
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: 06/10/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/12/2026
The quantity of what the sample constitutes: 4 Bags Combined Aggregate, 1 Can of Crum Rubber, 1 Can of Hi-Nat
A brief description of the sample: JMF Verif. 3/4" RHMA-G, 0.5% LAS PG64-16RB
From where was the sample collected: Manufacturer
Laboratory sample identification: 0316G-26
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Martin Marietta - Lake Elsinore
Source Identification (SMARA, name of Pit or Job Site): 91-33-0098
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
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number: 53418180T3
Lot number:
Sublot number:
Aggregate Mix Number:
