Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214135 DEA: 09213404 EFIS: 0900000030
QA Service Level: 1
DIST-CO-RTE-PM: 09-INY-395-29.9/41.8
Work Description: ROADWAY EXCAVATION, PLACE HMA (TYPE A), AND ALTERNATIVE PIPE CULVERT.
Location Description: INYO COUNTY NEAR OLANCHA AND CARTAGO FROM 1.4 MILES SOUTH OF LOS ANGELES AQUEDUCT BRIDGE TO 0.2 MILE SOUTH OF ASH CREEK BRIDGE
Contractor Name: FISHER SAND & GRAVEL CO.
Contractor Address: 1302 W DRIVERS WAY, TEPE, AZ. 85284
Resident Engineer: Kris Raber Structure Rep.: Alex Naime-Falcon
DIME Sample ID: 2023-08-18-41
TL Number from the TL Form:
Sample Submitted By Organization: CT D09 - Bishop Field Laboratory
Sample Organization Contact: (760) 872-5211
Type of Sample: Quality Assurance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 08/18/2023
Date that the sample was received by the laboratory/organization performing the testing: 08/18/2023
The quantity of what the sample constitutes: 12 Boxes HMA, 2 bags Cold Feed, 1 bag RAP, 3 QT cans PG70-10, 1 QT can Evotherm
A brief description of the sample: .75 WMA-SP-RAP
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Fisher Sand and Gravel
