Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214486 DEA: 080K1224 EFIS: 0815000244
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-15-R28.6/37.5
Work Description: REHBILIATATE EXISTING MAINLINE AND RAMP PAVEMENT
Location Description: SAN BERNARDINO COUNTY IN HESPERIA AND VICTORVILLE FROM OAK HILL ROAD OVERCROSSING TO 0.1 MILE SOUTH OF BEAR VALLEY ROAD OVERCROSSING
Contractor Name: SULLY - MILLER CONTRACTING COMPANY
Contractor Address: 135 S STATE COLLEGE BLVD. 400, BREA, CA 92821
Resident Engineer: Larry J Canuti Structure Rep.: Taghreed Al-khateeb
DIME Sample ID: 2023-06-05-44
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: 06/05/2023
Date that the sample was received by the laboratory/organization performing the testing: 06/13/2023
The quantity of what the sample constitutes: 3 Bags Of Comb. Agg, 8 Bags Of Bin Agg, 2 Bags Of Rap
A brief description of the sample: JMF 1" HMA-A-SP R25 1% LSM
From where was the sample collected: Fabricator
Laboratory sample identification: 0313A-23
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Blue Diamond-Victorville
Source Identification (SMARA, name of Pit or Job Site): 91-36-0046, 91-36-0022
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 Blue Diamond Victorville Plant
Where the material sample would have been placed if not sampled: Asphalt Paving
Primary Aggregate Nominal Size: 1 inch
The concrete mix design number: 300222-CPC R25
Lot number:
Sublot number:
Aggregate Mix Number:
