Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215620 DEA: 01436404 EFIS: 0100000193
QA Service Level: 1
DIST-CO-RTE-PM: 01-DN-101-35.8/36.5
Work Description: Dr. Fine Bridge Replacement
Location Description: DR. FINE BRIDGE REPLACEMENT FROM LAKE EARL DR TO S FRED D. HAIGHT DR ON HWY 101 ACROSS SMITH RIVER.
Contractor Name: MCM Construction
Contractor Address: PO Box 620, North Highlands, Ca 95660
Resident Engineer: Clayton Malmberg Structure Rep.: Brian Cinkutis
DIME Sample ID: 2024-09-17-29
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - Crescent City Field Laboratory
Sample Organization Contact: (707) 496-5581
Type of Sample: Quality Assurance
Type of Material: Aggregate
Sample Taken Date: 09/17/2024
Date that the sample was received by the laboratory/organization performing the testing: 09/17/2024
The quantity of what the sample constitutes: 3 Bags of Aggregate
A brief description of the sample: 2 bags of sand, 1 bag of 3/8 pea gravel
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier: 01-0041
Structure name: Dr fine bridge
The fabricator/manufacturer/facility name: Tidewater Starry pit
Source Identification (SMARA, name of Pit or Job Site): Tidewater Stary Pit
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: Sample was taken at the plant
Where the material sample would have been placed if not sampled: Pier 4(left)
Primary Aggregate Nominal Size: 3/8 inch
The concrete mix design number: FR-3/8 CIDH
Lot number:
Sublot number:
Aggregate Mix Number:
