Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215609 DEA: 074W9404 EFIS: 0720000196
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-101-0.0/1.0
Work Description: COLD PLANE AND OVERLAY WITH RUBBERIZED HOT MIX ASPHALT, SLURRY SEAL.
Location Description: LOS ANGELES COUNTY IN LOS ANGELES FROM ROUTE 10/101 SEPARATION TO SPRING STREET OVERCROSSING
Contractor Name: Sully Miller
Contractor Address: 135 State College Blvd, Brea, Ca 92821
Resident Engineer: Susana Facio Structure Rep.: Unknown
DIME Sample ID: 2021-07-23-8
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: Asphalt Rubber Binder
Sample Taken Date: 07/23/2021
Date that the sample was received by the laboratory/organization performing the testing: 07/27/2021
The quantity of what the sample constitutes: 1 Quart Can
A brief description of the sample: Asphalt Rubber Binder
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Blue Diamond Material-Irwindale
Asphalt modifier supplier:
Performance Grade: PG 64-16
Lot number:
Sublot number:
Asphalt Rubber Binder Mix Number:
