Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002260 DEA: 081N8104 EFIS: 0823000050
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-40-R135.9/R143.8
Work Description: RHMA-open graded (OGFC), cold plane AC Pvmt, & replace AC Surf.
Location Description:
Contractor Name: SULLY - MILLER CONTRACTING COMPANY
Contractor Address: 135 S STATE COLLEGE BLVD. 400, BREA, CA 92821
Resident Engineer: Anthony Doan Structure Rep.: Unknown
DIME Sample ID: 2026-07-15-64
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: JMF Verification
Type of Material: Crumb Rubber Modifier
Sample Taken Date: 07/15/2026
Date that the sample was received by the laboratory/organization performing the testing: 07/21/2026
The quantity of what the sample constitutes: 3Bgs Comb Cld-feed Ag 3Bgs 1/2",3/8" Crshd Ag Vir ea 2Bgs Mfd Sand,1Bg Crum Rbr,1Bag Hi-Nat
A brief description of the sample: 1/2" RHMA-G 1.0% LSM
From where was the sample collected: Manufacturer
Laboratory sample identification: 0425G-26
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Blue Diamond - Victorville
