Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000651 DEA: 010M7004 EFIS: 0123000057
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-101-109.55/125.73
Work Description: Orick Micro-Surfacing
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Ryan Dunne Structure Rep.: Unknown
DIME Sample ID: 2025-06-12-16
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: 06/12/2025
Date that the sample was received by the laboratory/organization performing the testing: 06/12/2025
The quantity of what the sample constitutes: 1 canvas bag
A brief description of the sample: Type 3 Slurry Seal/Micro-surfacing
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: knife river central point Oregon
Source Identification (SMARA, name of Pit or Job Site): Knife River
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: stockpile in the Orick yard
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: fine
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
