Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215494 DEA: 081H4904 EFIS: 0817000059
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-18-31.9/38.5
Work Description: COLD PLANE AC PAVEMENT AND OVERLAY WITH HMA (TYPE A).
Location Description: SAN BERNARDINO COUNTY FROM 0.1 MILE EAST OF HILLTOP CONNECTOR TO 0.5 MILE EAST OF SIBERIA CREEK TRAIL
Contractor Name: Matich Corp
Contractor Address: P.O. Box 10, Highland, CA 92346-1010
Resident Engineer: Nhan Nguyen Structure Rep.: Unknown
DIME Sample ID: 2021-09-01-14
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: 09/01/2021
Date that the sample was received by the laboratory/organization performing the testing: 09/02/2021
The quantity of what the sample constitutes: 2 boxes HMA
A brief description of the sample: 3/4" HMA-A SP R12 0.75% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0516A-21
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Matich-Lytle Creek
