Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002359 DEA: 070Y1204 EFIS: 0724000133
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-405-VAR
Work Description: RTE 405 PAVEMENT REHAB - INDIVIDUAL SLAB REPLACEMENT (RSC), LEAN CONCRETE BASE RAPID SETTING, BASE BOND BREAKER, RHMA-G, SLURRY SEAL, COLD PLANE, DRILL & BOND DOWELS, PAVEMENT DELINEATION, MODIFYING RAMP METERING & SIGNAL/LIGHTING SYSTEMS (166TH ST UC TO MANCHESTER BLVD OC)
Location Description:
Contractor Name: RV Concrete
Contractor Address: 605 E Commercial Street, Anaheim, CA 92801
Resident Engineer: Khanh-Van Nguyen Structure Rep.: Unknown
DIME Sample ID: 2026-08-11-71
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: Crumb Rubber Modifier
Sample Taken Date: 08/11/2026
Date that the sample was received by the laboratory/organization performing the testing: 08/18/2026
The quantity of what the sample constitutes: 1 Bag Crum Rubber, 1 Bag Hi-Nat
A brief description of the sample: 3/4" RWMA-G SP 0.50% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0527G-26
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: All American Asphalt-Irwindale
