Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994962 DEA: 07357304 EFIS: 0719000062
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-5-6.6/13.1
Work Description: REPLACE CONCRETE SLABS AND MEDIAN BARRIER,
Location Description: LOS ANGELES COUNTY IN SANTA FE SPRINGS, DOWNEY AND CITY OF COMMERCE FROM 0.2 MILE SOUTH OF ROUTE 5/605 SEPARATION TO 0.1 MILE NORT
Contractor Name: PETERSON-CHASE GENERAL ENGINEERING CONSTRUCTION, INC.
Contractor Address: 16351 Construction Circle West, Irvine, CA 92606
Resident Engineer: Martin Oregel Structure Rep.: Unknown
DIME Sample ID: 2023-10-11-117
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: 10/11/2023
Date that the sample was received by the laboratory/organization performing the testing: 11/06/2023
The quantity of what the sample constitutes: 4 bags of Agg, 1 bag of CRM Scrap and 1 bag of Hi-Nat
A brief description of the sample: JMF 1/2" RHMA-G-SP 1.0% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0565G-23
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: AAA- Corona/ Irwindale/ SJR/ ROHM & HAAS (Morelife)
