Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214820 DEA: 081K4604 EFIS: 0819000045
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-215-R36.6/R37.2
Work Description: ADD A S/B AND N/B AUX LANE
Location Description: RIVERSIDE COUNTY NEAR MORENO VALLEY FROM 0.2 MILE NORTH OF ALESSANDRO BOULEVARD OVERCROSSING TO 0.2 MILE SOUTH OF EUCALYPTUS AVENUE OVERCROSSING
Contractor Name: Riverside Construction Company
Contractor Address: 4225 Garner Road, Riverside CA, 92502
Resident Engineer: Paul Brown Structure Rep.: Hien Vu
DIME Sample ID: 2023-05-02-54
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: 05/02/2023
Date that the sample was received by the laboratory/organization performing the testing: 05/09/2023
The quantity of what the sample constitutes: 2 Bags of Aggs., 1 Bag of RAP
A brief description of the sample: PSUE 3/4" HMA-A-SP R15 NO LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0246A-23
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: All American Asphalt - Corona
Source Identification (SMARA, name of Pit or Job Site): 91-33-0005
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: 105927
Lot number:
Sublot number:
Aggregate Mix Number:
