Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214697 DEA: 07307104 EFIS: 0714000213
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-101-32.8
Work Description: CONSTRUCT BRIDGE.
Location Description: LOS ANGELES COUNTY IN AND NEAR AGOURA HILLS FROM 0.1 MILE WEST OF LIBERTY CANYON ROAD UNDERCROSSING TO 0.6 MILE EAST OF PALO COMADO OVERCROSSING
Contractor Name: CA Rasmussen
Contractor Address: 28548 LIVINGSTON AVENUE, VALENICA CA 91355
Resident Engineer: Sam Toutounchian Structure Rep.: Darwin Vargas
DIME Sample ID: 2024-08-28-44
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: 08/28/2024
Date that the sample was received by the laboratory/organization performing the testing: 08/30/2024
The quantity of what the sample constitutes: 24 BOXES RHMA 5 QTS PG64-16 4 QTS RB BLND 2 QTS LAS 1 QT EXT 1 CAN HN 1 CAN CRM 5 BAGS CMB AGG
A brief description of the sample: 3/4" RHMA G SP .5% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0447G-24
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: VULCAN SUN VALLEY
