Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215349 DEA: 081C0824 EFIS: 0816000087
QA Service Level: 1
DIST-CO-RTE-PM: 08-RIV-10-R104.9/R134.2
Work Description: PLACE HMA (TYPE A), JPCP AND IMPORTED BORROW.
Location Description: RIVERSIDE COUNTY FROM ROUTE 10/177 SEPARATION TO 1.1 MILES WEST OF WILEY'S WELL RD OC
Contractor Name: FISHER SAND & GRAVEL CO.
Contractor Address: 1302 W DRIVERS WAY, TEMPE, AZ. 85284
Resident Engineer: Khoi Vu Structure Rep.: Shukri Abouazra
DIME Sample ID: 2023-11-16-49
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: 11/16/2023
Date that the sample was received by the laboratory/organization performing the testing: 11/20/2023
The quantity of what the sample constitutes: 2 bags of each agg (virgin and marinated blend), 1 bag of each RAP (coarse and fine)
A brief description of the sample: PSUE 3/4" HMA-A-SP R24 1.0% LSM
From where was the sample collected: Manufacturer
Laboratory sample identification: 0583A-23
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Ehrenberg Pit/ Holly Frontier/ Lhoist/ Project Roadway
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: Fisher Sand and Gravel - Tempe
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: CA125MA
Lot number:
Sublot number:
Aggregate Mix Number:
