Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994599 DEA: 081N1604
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-40-R20.0/R28.1
Work Description: RHMA, HIGH DENSITY POLYURETHANE INJECTION, AND COLD PLANE AC PVMT.
Location Description: SAN BERNARDINO COUNTY NEAR BARSTOW FROM 0.3 MILE WEST OF NEWBERRY ROAD OVERCROSSING TO DESERT OASIS REST AREA
Contractor Name: SULLY-MILLER CONTRACTING COMPANY
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2024-04-03-30
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: Production Start-Up
Type of Material: Aggregate
Sample Taken Date: 04/03/2024
Date that the sample was received by the laboratory/organization performing the testing: 04/04/2024
The quantity of what the sample constitutes: 3 Bags 3/4", 3 Bags 1/2", 3 Bags 3/8", 2 Bags Sand, 2 Bags Combined Agg
A brief description of the sample: 3/4 RHMA-G
From where was the sample collected: Supplier
Laboratory sample identification: 0162G-24
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Blue Diamond Materials-Victorville
Source Identification (SMARA, name of Pit or Job Site): 91-36-0046, 91-36-0022
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 Blue Diamond Victorville Plant
Where the material sample would have been placed if not sampled: Roadway
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number: 300072-LSM
Lot number:
Sublot number:
Aggregate Mix Number:
