Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215349 DEA: 081C0824 EFIS: 0816000087
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-10-R104.9/R134.2
Work Description: PLACE HMA (TYPE A), JPCP AND IMPORTED BORROW.
Location Description: RIVERSIDE COUNTY FROM ROUTE 10/177 SEPARATION TO 1.1 MILES WEST OF WILEY'S WELL RD OC
Contractor Name: FISHER SAND & GRAVEL CO.
Contractor Address: 1302 W DRIVERS WAY, TEMPE, AZ. 85284
Resident Engineer: Khoi Vu Structure Rep.: Shukri Abouazra
DIME Sample ID: 2024-04-25-32
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: 04/25/2024
Date that the sample was received by the laboratory/organization performing the testing: 04/30/2024
The quantity of what the sample constitutes: 1 Bag Coldfeed,6 Bags Agg, 1 Bag each Of Scrap & Hi-Nat
A brief description of the sample: JMF 1/2" RHMA-G
From where was the sample collected: Manufacturer
Laboratory sample identification: 0205G-24
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Fisher Sand and Gravel-Tempe
Source Identification (SMARA, name of Pit or Job Site): Fisher Sand & Gravel Co.
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 Fisher Sand and Gravel
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: 529SKR
Lot number:
Sublot number:
Aggregate Mix Number:
