Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215697 DEA: 07318204 EFIS: 0715000286
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-Route 1-4.0/4.2
Work Description: CM/GC Project - Work consists of constructing secant wall and slope restoration
Location Description: near Point Mugu State Park 0.4 mile South of Sycamore Canyon Road.
Contractor Name: Flatiron/Drill Tech, a Joint Venture
Contractor Address: 15335 Fairfield Ranch Rd, Chino Hills, CA 91709
Resident Engineer: Saeid Shakeri Structure Rep.: Azizollah Maghsoudloo
DIME Sample ID: 2024-04-15-31
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: 04/15/2024
Date that the sample was received by the laboratory/organization performing the testing: 04/16/2024
The quantity of what the sample constitutes: 3 Bags of Agg., 1 Bag of RAP
A brief description of the sample: PSUE 1/2" HMA-A-SP R15
From where was the sample collected: Manufacturer
Laboratory sample identification: 0178A-24
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: All American Asphalt - Corona/ SJR
Source Identification (SMARA, name of Pit or Job Site): 91-33-0005
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: All American Asphalt - Irwindale
Where the material sample would have been placed if not sampled: Asphalt Paving
Primary Aggregate Nominal Size: 1/2 inch
The concrete mix design number: 104775
Lot number:
Sublot number:
Aggregate Mix Number:
