Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993418 DEA: 07324404 EFIS: 0716000077
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-22-0.0/1.5
Work Description: PLACE RHMA-G AND MODIFY SIGNAL AND LIGHTING SYSTEM.
Location Description: LOS ANGELES COUNTY IN LONG BEACH FROM ROUTE 1 TO SAN GABRIEL RIVER UNDERCROSSING
Contractor Name: Sulley Miller Contracting Co.
Contractor Address: 135 S. State College Blvd. Suite 400, Brea, CA 92821
Resident Engineer: Thang Ton Structure Rep.: Unknown
DIME Sample ID: 2022-09-06-74
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: 09/06/2022
Date that the sample was received by the laboratory/organization performing the testing: 09/19/2022
The quantity of what the sample constitutes: 1 Bag Hi-Nat
A brief description of the sample: Hi-Natural
From where was the sample collected: Manufacturer
Laboratory sample identification: 0643G-22
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Blue Diamond Material-Irwindale
