Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002614 DEA: 081K6304 EFIS: 0819000083
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-18-T6.0/9.1
Work Description: CONSTRUCTION ON STATE HIGHWAY IN SAN BERNARDINO COUNTY IN SAN BERNARDINO FROM 29TH STREET TO 0.2 MILE SOUTH OF OLD WATERMAN CANYON ROAD.
Location Description: SAN BERNARDINO COUNTY IN THE CITY OF SAN BERNARDINO ON WATERMAN AVE
Contractor Name: Maneri Traffic Control
Contractor Address: 4949 SECOND STREET, FALLBROOK, CA 92028
Resident Engineer: Shaun Loza Structure Rep.: Unknown
DIME Sample ID: 2026-10-05-46
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: 10/05/2026
Date that the sample was received by the laboratory/organization performing the testing: 10/08/2026
The quantity of what the sample constitutes: 2 Bags of Comb. Agg. 2 Bags of RAP Coarse
A brief description of the sample: 3/4" HMA-A R20 0.5% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Matich Corporation - Lytle Creek
Source Identification (SMARA, name of Pit or Job Site): 91-36-0040
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:
