Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994147 DEA: 120R4104 EFIS: 1218000090
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-1-17.4/21.5
Work Description: COLD PLANE AC AND PLACE RHMA-G.
Location Description: ORANGE COUNTY IN NEWPORT BEACH FROM JAMBOREE ROAD TO SANTA ANA RIVER BRIDGE
Contractor Name: R.J. NOBLE COMPANY
Contractor Address: 15505 E. Lincoln Ave, Orange, CA 92865
Resident Engineer: Omid Mazdiyasni Structure Rep.: Unknown
DIME Sample ID: 2024-04-08-68
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: Crumb Rubber Modifier
Sample Taken Date: 04/08/2024
Date that the sample was received by the laboratory/organization performing the testing: 04/09/2024
The quantity of what the sample constitutes: 1 Bag CRM Scrap
A brief description of the sample: 1 Bag Crumb Rubber Scrap
From where was the sample collected: Manufacturer
Laboratory sample identification: 0165G-24
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan-Corona/ Chandler Agg/ World ASP/ Ingevity
