Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000854 DEA: 010M7104 EFIS: 0123000058
QA Service Level: 1
DIST-CO-RTE-PM: 01-DN-101-46.18
Work Description: Resurface Smith River Agricultural Inspection Station
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2024-12-10-24
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: 12/10/2024
Date that the sample was received by the laboratory/organization performing the testing: 12/10/2024
The quantity of what the sample constitutes: 750 Tons
A brief description of the sample: 1/2 inch cold feed agg
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name: 101/AGG/STATION
The fabricator/manufacturer/facility name: Tidewater Smith River
Source Identification (SMARA, name of Pit or Job Site): Starry pitt
The fabricator's/manufacturer's product name for the sample: 1/2 inch agg
The fabricator/manufacturer designation for the sample:
The plant number:
A detailed description of where the material sample was collected: 1/2 inch cold feed agg
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1/2 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
