Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993508 DEA: 070W1104 EFIS: 0721000059
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-210-R35.9/R52.2
Work Description: COLD PLANE OVERLAY, INDIVIDUAL REPLACEMENT SLAB AND TRAFFIC STRIPING.
Location Description: LOS ANGELES COUNTY FROM HIGHLAND AVENUE UNDERCROSSING IN DUARTE TO SAN ANTONIO WASH BRIDGE IN CLAREMONT.
Contractor Name: Pavement Coatings
Contractor Address: 10240 San Sevaine Way, Jurupa Valley, CA 91752
Resident Engineer: Moe Izadpanah Structure Rep.: Unknown
DIME Sample ID: 2023-05-18-68
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: 05/18/2023
Date that the sample was received by the laboratory/organization performing the testing: 05/25/2023
The quantity of what the sample constitutes: 2 Bags of Agg., 1 Bag of RAP
A brief description of the sample: PSUE 3/4" HMA-A-SP R15 0.5% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0271A-23
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan Materials - Irwindale
Source Identification (SMARA, name of Pit or Job Site): 91-19-0035
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 Vulcan Materials - Irwindale
Where the material sample would have been placed if not sampled: Asphalt Paving
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number: 220831A IRW LTR
Lot number:
Sublot number:
Aggregate Mix Number:
