Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000106 DEA: 07316204 EFIS: 0715000198 Permit Numbers: 0722AOP1994
QA Service Level: 2
DIST-CO-RTE-PM: 07---
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Ramy Beshara Structure Rep.: Unknown
DIME Sample ID: 2024-03-11-18
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: 03/11/2024
Date that the sample was received by the laboratory/organization performing the testing: 03/15/2024
The quantity of what the sample constitutes: 4 Bags Coldfeed Agg, 2 bags Rap
A brief description of the sample: JMF 3/4" HMA-A-SP R25
From where was the sample collected: Manufacturer
Laboratory sample identification: 0137A-24
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Granite Construction - Big Rock
Source Identification (SMARA, name of Pit or Job Site): 91-19-0046
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 Granite-Bigrock
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: 14343
Lot number:
Sublot number:
Aggregate Mix Number:
