Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000888 DEA: 07346304 EFIS: 0718000073
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-101-7.9/11.8
Work Description: INSTALL RUBBERIZED HOT MIXED ASPHALT.
Location Description: LOS ANGELES COUNTY IN THE CITY AND COUNTY OF LOS ANGELES FROM 0.1 MILE SOUTH OF PILGRIMAGE OVERCROSSING TO ROUTE 101/170 SEPARATION.
Contractor Name: CHUMO CONSTRUCTION, INC.
Contractor Address: Unknown
Resident Engineer: Denrick Bautista Structure Rep.: Peter Wang
DIME Sample ID: 2026-09-08-22
TL Number from the TL Form: A98261
Sample Submitted By Organization: CT D07 - Plant Services, Unit 1841
Sample Organization Contact: (562) 345-3126
Type of Sample: Acceptance
Type of Material: Aggregate
Sample Taken Date: 09/08/2026
Date that the sample was received by the laboratory/organization performing the testing: 09/09/2026
The quantity of what the sample constitutes: 600 Tons
A brief description of the sample: 1/2 HMA combined agg (coarse and fine)
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: AAA-Irwindale
Source Identification (SMARA, name of Pit or Job Site): 91-33-0005
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: Cold Feed Sampling Chute
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1/2 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
