Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993805 DEA: 070W1404 EFIS: 0721000062
QA Service Level: 1
DIST-CO-RTE-PM: 07-VEN-1-4.4/9.7
Work Description: COLD PLACE AC PAVEMENT AND PLACE RHMA-G.
Location Description: VENTURA COUNTY FROM BIG SYCAMORE MAINTENANCE STATION AND PARK TO 0.2 MILE SOUTH OF GALLEGUAS GREEK BRIDGE
Contractor Name: C A RASMUSSEN INC
Contractor Address: 28548 LIVINGSTON AVENUE, VALENCIA CA 91355
Resident Engineer: Ranjit Singh Structure Rep.: Unknown
DIME Sample ID: 2022-10-25-60
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: 10/25/2022
Date that the sample was received by the laboratory/organization performing the testing: 10/28/2022
The quantity of what the sample constitutes: 1 Qt. OF CRM
A brief description of the sample: CRM Scrap
From where was the sample collected: Manufacturer
Laboratory sample identification: 0716G-22
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan Materials-Saticoy
