Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002156 DEA: 081P8304 EFIS: 0824000136
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-15-33.2/33.2
Work Description: REHABILITATE 30" CSP CULVERTS
Location Description: IN RIVERSIDE COUNTY AT TEMESCAL VALLEY AT TEMESCAL CANYON ROAD UNDERCROSSING
Contractor Name: INTERSTATE CIVIL CONSTRUCTION
Contractor Address: 6025 Park Dr, Wrightwood, CA 92397
Resident Engineer: Kohnson V Chan Structure Rep.: Unknown
DIME Sample ID: 2026-08-07-27
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: Aggregate
Sample Taken Date: 08/07/2026
Date that the sample was received by the laboratory/organization performing the testing: 08/11/2026
The quantity of what the sample constitutes: 4 Bags of Cold-feed, 1 Bag of Hi Nat, 1 Bag Crum Rubber
A brief description of the sample: 3/4" RWMA-G PG64-16RB
From where was the sample collected: Manufacturer
Laboratory sample identification: 0513G-26
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan - Irwindale
Source Identification (SMARA, name of Pit or Job Site): 91-19-0035 / 91-33-0027
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:
