Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214493 DEA: 07311704 EFIS: 0715000013
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-134-0.0/R13.3
Work Description: CONCRETE SLAB REPLACEMENT, HMA PAVING, ELECTRICAL AND LANDSCAPE WORK.
Location Description: LOS ANGELES COUNTY IN LOS ANGELES, BURBANK, GLENDALE AND PASADENA FROM ROUTE 101/134 SEPARATION TO JUNCTION OF ROUTE 210/710
Contractor Name: PETERSON-CHASE GENERAL ENGINEERING CONSTRUCTION, INC.
Contractor Address: 16351 Construction Circle West, Irvine, CA 92606-4414
Resident Engineer: David Ayala Vanegas Structure Rep.: Unknown
DIME Sample ID: 2022-10-24-20
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: 10/24/2022
Date that the sample was received by the laboratory/organization performing the testing: 10/27/2022
The quantity of what the sample constitutes: 1 Bag Hi-Nat
A brief description of the sample: Hi-Natural
From where was the sample collected: Manufacturer
Laboratory sample identification: 0713G-22
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: All American Asphalt-Irwindale
