Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002561 DEA: 073XE403 EFIS: 0726000375
QA Service Level: 1
DIST-CO-RTE-PM: 07---unknown
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2026-07-24-43
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: 07/24/2026
Date that the sample was received by the laboratory/organization performing the testing: 08/17/2026
The quantity of what the sample constitutes: 4 Bags of Combined Aggregate & 2 Bags of Combined RAP
A brief description of the sample: -SP R25 0.75% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0524A-26
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan - Irwindale
Source Identification (SMARA, name of Pit or Job Site): 91-19-0016 / 91-19-0035
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:
