Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215109 DEA: 081C8504 EFIS: 0813000047
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-74-0.0/5.8
Work Description: ROADWAY EXCAVATION, HOT MIX ASPHALT, AND STRUCTURAL SHOTCRETE WALLS.
Location Description: RIVERSIDE COUNTY NEAR LAKE ELSINORE FROM ORANGE COUNTY LINE TO MONTE VISTA STREET
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: 38000 MONROE STREET, INDIO, CA 92203
Resident Engineer: Osama Abdalla Structure Rep.: Ryan Kash (Reports)
DIME Sample ID: 2023-09-22-82
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: Asphalt Rubber Binder
Sample Taken Date: 09/22/2023
Date that the sample was received by the laboratory/organization performing the testing: 09/25/2023
The quantity of what the sample constitutes: 1 Can
A brief description of the sample: Asphalt Rubber Binder, PG 64-16 CR
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: MM-Lake Elsinore
Asphalt modifier supplier:
Performance Grade: PG 64-16
Lot number:
Sublot number:
Asphalt Rubber Binder Mix Number:
