Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212739 DEA: 081J4004
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-40-149.3, 149.30
Work Description: Repair damaged pavement
Location Description:
Contractor Name: SULLY-MILLER CONTRACTING COMPANY
Contractor Address: 135 S. STATE COLLEGE BLVD., BREA, CA 92821
Resident Engineer: JOSE TORRES Structure Rep.: Unknown
DIME Sample ID: 2026-08-10-40
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: Acceptance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 08/10/2026
Date that the sample was received by the laboratory/organization performing the testing: 08/11/2026
The quantity of what the sample constitutes: ml
A brief description of the sample: Portable Skid Test
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Granite Rock
