Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994084 DEA: 060U8804 EFIS: 0616000074
QA Service Level: 1
DIST-CO-RTE-PM: 06-TUL-99-26.3/27.6
Work Description: CONSTRUCT A NEW INTERCHANGE AT COMMERCIAL AVENUE NOW CALLED INTERNATIONAL AGRI-CENTER WAY
Location Description: ON STATE ROUTE 99
Contractor Name: SECURITY PAVING COMPANY INC
Contractor Address: 13170 TELEFAIR AVE, SYLMAR, CA 91342
Resident Engineer: Alberto Lopez Structure Rep.: Vicente Sanchez
DIME Sample ID: 2025-03-20-46
TL Number from the TL Form:
Sample Submitted By Organization: CT D06 - Visalia Field Laboratory
Sample Organization Contact: (559) 974-1304
Type of Sample: Quality Assurance
Type of Material: Aggregate
Sample Taken Date: 03/20/2025
Date that the sample was received by the laboratory/organization performing the testing: 03/21/2025
The quantity of what the sample constitutes: Concrete Aggregates
A brief description of the sample: 1 Bag each of 1x4, 3/8 and Fines
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Cal Portland Porterville
Source Identification (SMARA, name of Pit or Job Site): 91-54-0022
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: Conveyor Belt
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
