Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214549 DEA: 081H2904 EFIS: 0817000006
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-173-18.7
Work Description: STRUCTURAL CONCRETE SOIL NAIL WALL AND SOLDIER PILE WALL.
Location Description: SAN BERNARDINO COUNTY NEAR CEDAR GLEN AT 0.1 MILE SOUTH OF HOSPITAL ROAD
Contractor Name: Stronghold Engineering, Inc.
Contractor Address: 150 W. Walnut Ave, Perris, CA 92571
Resident Engineer: Elvira Lenart Structure Rep.: Ravinder Singh
DIME Sample ID: 2023-12-06-7
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: 12/06/2023
Date that the sample was received by the laboratory/organization performing the testing: 12/07/2023
The quantity of what the sample constitutes: 2 bags of Agg., 1 bag of RAP
A brief description of the sample: PSUE 3/4" HMA-A R15 0.5% LAS
From where was the sample collected: Manufacturer
Laboratory sample identification: 0608A-23
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cemex Lytle Creek/ Valero/ Pre Tech INC
Source Identification (SMARA, name of Pit or Job Site): 91-36-0040
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 Matich Plant Rialto
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: LHP-63D
Lot number:
Sublot number:
Aggregate Mix Number:
