Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994648 DEA: 070W3904 EFIS: 0722000045
QA Service Level: 1
DIST-CO-RTE-PM: 07-VEN-101-10.7/26.7
Work Description: SLURRY SEAL.
Location Description: VENTURA COUNTY FROM CAMARILLO SPRINGS ROAD UNDERCROSSING IN CAMARILLO TO MAIN STREET UNDERCROSSING IN VENTURA
Contractor Name: INTERMOUNTAIN SLURRY SEAL, INC.
Contractor Address: 1120 TERMINAL WAY, RENO NV 89502
Resident Engineer: Denrick Bautista Structure Rep.: Unknown
DIME Sample ID: 2023-11-27-20
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: 11/27/2023
Date that the sample was received by the laboratory/organization performing the testing: 11/30/2023
The quantity of what the sample constitutes: PSUE 3/4" WMA-A-SP R15 0.50% EVO
A brief description of the sample: 2 Bags of each Bin Agg. (1,2,3,4), 1 Bag of RAP:
From where was the sample collected: Manufacturer
Laboratory sample identification: 0589A-23
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Fish Canyon Irwindale/ Vulcan Sun Valley/Ingevity/ VLO
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: Vulcan Sun Valley Plant
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: 220826 SVA VLO
Lot number:
Sublot number:
Aggregate Mix Number:
