Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215559 DEA: 112N0574 EFIS: 1119000079
QA Service Level: 1
DIST-CO-RTE-PM: 11-IMP-86-L8.4/8.8
Work Description: COLD PLANE AND PAVE WITH STRESS ABSORBING MEMBRANE INTERLAYER AND HMA.
Location Description: IMPERIAL COUNTY IN EL CENTRO FROM 0.1 MILE EAST OF NORTH IMPERIAL AVENUE TO TRESHILL ROAD.
Contractor Name: CALMEX ENGINEERING, INC.
Contractor Address: 2764 S Vista Ave, Bloomington, CA 92316
Resident Engineer: Benjamin Haney Structure Rep.: Unknown
DIME Sample ID: 2021-06-03-42
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: Crumb Rubber Modifier
Sample Taken Date: 06/03/2021
Date that the sample was received by the laboratory/organization performing the testing: 09/07/2021
The quantity of what the sample constitutes: 1 Can of Scrap Crumb Rubber
A brief description of the sample: Crumb Rubber Scrap
From where was the sample collected: Manufacturer
Laboratory sample identification: 4626
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Not Provided
