Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001002 DEA: 09396904 EFIS: 0924000027
QA Service Level: 1
DIST-CO-RTE-PM: 09-MNO-395-106.3/108.0
Work Description: CONSTRUCT MICRO-SURFANCING AND PLACE DELINEATION.
Location Description: MONO COUNTY AT WALKER FROM EAST SIDE LANE TO 0.5 MILE NORTH OF HACKNEY DRIVE
Contractor Name: VSS INTERNATIONAL, INC.
Contractor Address: Unknown
Resident Engineer: Malissa Reynolds Structure Rep.: Unknown
DIME Sample ID: 2025-07-23-22
TL Number from the TL Form:
Sample Submitted By Organization: CT D09 - Bishop Field Laboratory
Sample Organization Contact: (760) 872-5211
Type of Sample: Acceptance
Type of Material: Aggregate
Sample Taken Date: 07/23/2025
Date that the sample was received by the laboratory/organization performing the testing: 07/24/2025
The quantity of what the sample constitutes: 1 Bag of Slurry Seal Aggs
A brief description of the sample: Slurry Sand
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: NA
Source Identification (SMARA, name of Pit or Job Site): NA
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 @ Site
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1/4 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
