Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214573 DEA: 073096U4 EFIS: 0719000091
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-210-R0.0/R9.7
Work Description: PLACE CONCRETE PAVEMENT, BARRIER, HMA, DRAINAGE, AND ELECTRICAL.
Location Description: LOS ANGELES COUNTY IN LOS ANGELES FROM INTERSTATE 5 TO WHEATLAND AVENUE UNDERCROSSING
Contractor Name: FLATIRON WEST INC
Contractor Address: 15335 FAIRFIELD RANCH ROAD, CHINO HILLS, CA 91709
Resident Engineer: Ridwan Salman Structure Rep.: Adriana Pimienta
DIME Sample ID: 2023-05-08-50
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: Aggregate
Sample Taken Date: 05/08/2023
Date that the sample was received by the laboratory/organization performing the testing: 05/15/2023
The quantity of what the sample constitutes: 2 bags of each Bin (1,2,3,4,5), 2 bags of RAP
A brief description of the sample: PSUE 3/4" HMA-A-SP R15 0.50% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0253A-23
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan Materials - Sun Valley
Source Identification (SMARA, name of Pit or Job Site): 91-19-0035
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
The plant number:
A detailed description of where the material sample was collected: Manufacturer
Where the material sample would have been placed if not sampled: Asphalt Paving
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number: 220831 SVA LTR
Lot number:
Sublot number:
Aggregate Mix Number:
