Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995059 DEA: 081G6404 EFIS: 0816000046
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-395-R4.0/49.0
Work Description: REPLACE ASPHALT CONCRETE SURFACING, COLD PLANE AC PVMT AND RHMA.
Location Description: SAN BERNARDINO COUNTY AT VARIOUS LOCATIONS FROM ROUTE 15/395 SEPARATION TO 3.1 MILES NORTH OF ROUTE 58/395 SEPARATION
Contractor Name: SULLY-MILLER CONTRACTING COMPANY
Contractor Address: 135 S State College Blvd, Brea, Ca 92821
Resident Engineer: Shaun Loza Structure Rep.: Unknown
DIME Sample ID: 2024-07-23-17
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: Hot Mix Asphalt
Sample Taken Date: 07/23/2024
Date that the sample was received by the laboratory/organization performing the testing: 07/24/2024
The quantity of what the sample constitutes: 24 BOX HMA, 3 BAGS (3/4",3/8", 1/2"), 2 BAGS SAND, 3 BAGS COMB AGG, 2 BAGS RAP, 4 QTS PG58-16
A brief description of the sample: 3/4" HMA-A-SP R25 1.0% LSM
From where was the sample collected: Manufacturer
Laboratory sample identification: 0345A-24
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Blue Diamond-Victorville
