Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994869 DEA: 073237U4 EFIS: 0720000224
QA Service Level: 1
DIST-CO-RTE-PM: 07-VEN-150-13.3/19
Work Description: PLACE HMA (TYPE A) AND COLD PLANE ASPHALT
Location Description: VENTURA COUNTY IN AND NEAR OJAI FROM BURNHAM ROAD TO GORHAM ROAD
Contractor Name: C. A. RASMUSSEN INC.
Contractor Address: 28548 Livingston Ave., Valencia, CA, 91355
Resident Engineer: Denrick Bautista Structure Rep.: Unknown
DIME Sample ID: 2023-10-28-11
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: 10/28/2023
Date that the sample was received by the laboratory/organization performing the testing: 10/31/2023
The quantity of what the sample constitutes: 4 Bags Of Combined Agg., 1 Bag Rap
A brief description of the sample: HMA-A-SP R25 0.5% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0555A-23
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan - Saticoy
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: Belt Cut at Vulcan-Saticoy
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: 220200 SAT LTR
Lot number:
Sublot number:
Aggregate Mix Number:
