Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993815 DEA: 081C0814 EFIS: 0816000086
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-10-R60.7/R74.3
Work Description: I-10 PAVEMENT REHABILITATION (SEGMENT 1) PROJECT
Location Description: Coachella
Contractor Name: COFFMAN SPECIALTIES, INC
Contractor Address: 4375 JUTLAND DRIVE STE 260, SAN DIEGO CA 92117
Resident Engineer: Michael Sergah Structure Rep.: Al Alina
DIME Sample ID: 2024-02-02-8
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: Hot Mix Asphalt
Sample Taken Date: 02/02/2024
Date that the sample was received by the laboratory/organization performing the testing: 02/05/2024
The quantity of what the sample constitutes: 24 boxes HMA, 6 BAGS AGG, 2BAGS RAP, I BAG DUST, 4 QT OIL, 2QT LAS
A brief description of the sample: 1/2" HMA-A R25% ML5000
From where was the sample collected: Manufacturer
Laboratory sample identification: 0110A-24
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Coachella Valley Aggregates/VALERO/INGVITY
