Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214708 DEA: 07323904 EFIS: 0716000072
QA Service Level: 1
DIST-CO-RTE-PM: 07---
Work Description: COLD PLANE AC, PLACE RUBBERIZED HOT MIX AS
Location Description: VENTURA COUNTY NEAR VENTURA FROM ROUTE 1/101 SEPARATION TO MOBIL PIER ROAD.
Contractor Name: C. A. Rasmussen, Inc.
Contractor Address: 28548 Livingston Avenue, Valencia, CA 91355
Resident Engineer: Alfred Ira Structure Rep.: Unknown
DIME Sample ID: 2023-11-28-42
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: 11/28/2023
Date that the sample was received by the laboratory/organization performing the testing: 12/01/2023
The quantity of what the sample constitutes: 8 bags of agg., 3 bags of RAP
A brief description of the sample: PSUE 3/4" HMA-A-SP R22, PG64-10, 0.50% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0591A-23
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Saticoy/ ArrMaz Ad-Here LOF 65-00/ SJR/ Palmdale/ San Emidio/ Fish Canyon
Source Identification (SMARA, name of Pit or Job Site): 91-19-0035, 91-15-0041, 91-19-0020
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: Vulcan - Saticoy
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: 220831 SAT SJR
Lot number:
Sublot number:
Aggregate Mix Number:
