Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994583 DEA: 07333604 EFIS: 0716000313
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-2-2.3/14.2
Work Description: COLD PLANE AC, PLACE HMA, REPLACE CURB RAMPS AND TRAFFIC SIGNALS.
Location Description: LOS ANGELES COUNTY IN LOS ANGELES AT VARIOUS LOCATIONS FROM CENTINELA AVENUE TO GLENDALE BOULEVARD UNDERCROSSING
Contractor Name: SULLY-MILLER CONTRACTING COMPANY
Contractor Address: Unknown
Resident Engineer: Salman Ridwan Structure Rep.: Gon Choi
DIME Sample ID: 2026-10-06-37
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: Crumb Rubber Modifier
Sample Taken Date: 10/06/2026
Date that the sample was received by the laboratory/organization performing the testing: 10/13/2026
The quantity of what the sample constitutes: 6 Bags of Cold feed, 1 Bag of Crum Rubber, 1 Bag of Hi-Nat
A brief description of the sample: 3/4" RWMA G EVO .6%
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Blue Diamond - Victorville
