Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000777 DEA: 07370404 EFIS: 0720000128
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-R59.5/R73.7
Work Description: COLD PLANE AC PAVEMENT, PLACE HOT MIX ASPHALT AND INSTALL MGS.
Location Description: LOS ANGELES COUNTY FROM LAKE HUGHES ROAD UNDERCROSSING TO 0.7 MILE SOUTH OF VISTA DEL LAGO ROAD OVERCROSSING.
Contractor Name: GRIFFITH COMPANY
Contractor Address: 1128 Carrier Parkway Avenue, Bakersfield, CA 93308
Resident Engineer: Ridwan Salman Structure Rep.: Unknown
DIME Sample ID: 2026-08-07-11
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: 08/07/2026
Date that the sample was received by the laboratory/organization performing the testing: 08/07/2026
The quantity of what the sample constitutes: 4 Bags Cold Feed, 10 Bags 3/4", 1/2", 3/8", RD, WRD - 2 bags each, 3 Qrts Cru Rubber, 3 Qrts Hi-Nat
A brief description of the sample: Milestone (120K) 3/4" RHMA-G-SP 1.0% LSM
From where was the sample collected: Manufacturer
Laboratory sample identification: 0490G-26
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Griffith Edmonston-Lebec
Source Identification (SMARA, name of Pit or Job Site): 91-15-0068
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:
