Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215360 DEA: 112N0454 EFIS: 1118000198
QA Service Level: 1
DIST-CO-RTE-PM: 11-SD-94-30.0/39.0
Work Description: PLACING CHIP SEAL, SLURRY SEAL, SHOULDER BACKING AND STRIPING.
Location Description: SAN DIEGO COUNTY NEAR DULZURA AND BARRETT JUNCTION FROM 0.9 MILE EAST OF GRANDE CREEK BRIDGE TO ROUTE 188.
Contractor Name: American Pavement Systems, Inc.
Contractor Address: 1012 11th Street, Suite 1000, Modesto, CA 95354
Resident Engineer: Benjamin Haney Structure Rep.: Unknown
DIME Sample ID: 2021-10-27-23
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: 10/27/2021
Date that the sample was received by the laboratory/organization performing the testing: 11/10/2021
The quantity of what the sample constitutes: 1 Bag of Scrap Crumb Rubber
A brief description of the sample: Crumb Rubber Scrap for use in Chip Seal
From where was the sample collected: Manufacturer
Laboratory sample identification: 5149
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Plant
