Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994781 DEA: 07322704 EFIS: 0716000067
QA Service Level: 1
DIST-CO-RTE-PM: 07-VEN-1-1.3/26.6
Work Description: CONSTRUCT PERVIOUS CONCRETE PAVEMENT
Location Description: VENTURA COUNTY AT VARIOUS LOCATIONS
Contractor Name: AUTOBAHN CONSTRUCTION
Contractor Address: 933 North Batavia Street, Orange, CA 92867
Resident Engineer: Ranjit Singh Structure Rep.: Unknown
DIME Sample ID: 2024-08-22-47
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: 08/22/2024
Date that the sample was received by the laboratory/organization performing the testing: 08/27/2024
The quantity of what the sample constitutes: 20 BX RHMA 4 QTS PG64-16 4 QTS RB BLND 1 QT EVO 1 QT EXT 4 BAGS CMB AGG 1 CAN CRM 1 CAN HN
A brief description of the sample: 3/4" RWMA G SP .25% EVO
From where was the sample collected: Manufacturer
Laboratory sample identification: 0434G-24
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan Saticoy
