Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213746 DEA: 080Q75U4 EFIS: 0817000114
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD,RIV-60-R4.6/R9.9, R0.0/12.2
Work Description: REPLACEMENT OF TWO OUTSIDE LANES AND CONCRETE SLABS
Location Description:
Contractor Name: J McLoughlin Engineering
Contractor Address: 10641 Fulton Court, Rancho Cucamonga, CA 91730
Resident Engineer: Mujahid Qureshi Structure Rep.: Ching Chuang
DIME Sample ID: 2021-05-17-18
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: Acceptance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 05/17/2021
Date that the sample was received by the laboratory/organization performing the testing: 05/19/2021
The quantity of what the sample constitutes: 4 boxes RHMA
A brief description of the sample: 3/4" RHMA-G PG 64-16RB 0.5% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0290G-21
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan Corona
