Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214336 DEA: 07302404 EFIS: 0713000488
QA Service Level: 1
DIST-CO-RTE-PM: 07-VEN-101-37/40
Work Description: PADRE JUAN REHAB
Location Description: VEN 101
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: 4820 McGrath Street, Suite 101, Ventura, CA 93003
Resident Engineer: Alfred Ira Structure Rep.: Unknown
DIME Sample ID: 2023-10-27-41
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: 10/27/2023
Date that the sample was received by the laboratory/organization performing the testing: 11/01/2023
The quantity of what the sample constitutes: 1 Qt. Of Scrap
A brief description of the sample: Scrap
From where was the sample collected: Manufacturer
Laboratory sample identification: 0560G-23
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Granite Construction - Santa Paula
