Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000409 DEA: 051S1604 EFIS: 0524000176
QA Service Level: 1
DIST-CO-RTE-PM: 05-MON-1-60
Work Description: Rocky Creek Slip Out Permanent Restoration Project
Location Description:
Contractor Name: Gordon N Ball, Inc. (Fred Velasco/Stuart Yamamoto)
Contractor Address: 333 Camille Avenue, Alamo, CA 94507
Resident Engineer: Jorge Uberhuaga Structure Rep.: Daniel Dait
DIME Sample ID: 2024-10-07-20
TL Number from the TL Form:
Sample Submitted By Organization: Con-Fab California Corporation - Lathrop
Sample Organization Contact: (209) 249-4700
Type of Sample: Quality Control
Type of Material: Aggregate
Sample Taken Date: 10/07/2024
Date that the sample was received by the laboratory/organization performing the testing: 10/07/2024
The quantity of what the sample constitutes: 1 Bucket of 1/2", 1 Bucket of 3/8", One Bucket of Sand
A brief description of the sample: 1 Bucket of 1/2", 1 Bucket of 3/8", One Bucket of Sand
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: ConFab Lathrop
Source Identification (SMARA, name of Pit or Job Site): Con-Fab California, LLC
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: Storage Bin
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1/2 inch
The concrete mix design number: VER-95LV
Lot number:
Sublot number:
Aggregate Mix Number:
