Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993508 DEA: 070W1104 EFIS: 0721000059
QA Service Level: 1
DIST-CO-RTE-PM: 07-LA-210-R35.9/R52.2
Work Description: COLD PLANE OVERLAY, INDIVIDUAL REPLACEMENT SLAB AND TRAFFIC STRIPING.
Location Description: LOS ANGELES COUNTY FROM HIGHLAND AVENUE UNDERCROSSING IN DUARTE TO SAN ANTONIO WASH BRIDGE IN CLAREMONT.
Contractor Name: Pavement Coatings
Contractor Address: 10240 San Sevaine Way, Jurupa Valley, CA 91752
Resident Engineer: Moe Izadpanah Structure Rep.: Unknown
DIME Sample ID: 2023-05-15-28
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: 05/15/2023
Date that the sample was received by the laboratory/organization performing the testing: 05/17/2023
The quantity of what the sample constitutes: 1 Bag of Hi-Natural Crumb Rubber
A brief description of the sample: Crumb Rubber Hi-Nat
From where was the sample collected: Manufacturer
Laboratory sample identification: 0259G-23
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan Materials - Irwindale
DIME Test ID: 2023-05-15-28-1
Test Method: CTM 385-November 2016: Method of Test for Crumb Rubber Modifier (CRM)
Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Organization Address: 13970 Victoria Street,
Organization City: Fontana
Organization State: CA
Organization Zipcode: 92336
Organization Email: jose.guzman@dot.ca.gov
Organization Phone: (909) 829-3029
Data has not been verified.
