Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
DEA: No Project
QA Service Level:
DIST-CO-RTE-PM: ---
Work Description: Special project identifier for material not associated with a project
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2025-09-02-38
TL Number from the TL Form:
Sample Submitted By Organization: Stonemont Solutions, Incorporated
Sample Organization Contact: (970) 674-1148
Type of Sample: Quality Control
Type of Material: Aggregate
Sample Taken Date: 09/02/2025
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes:
A brief description of the sample: Aggregate
From where was the sample collected: Source
Laboratory sample identification: 1301012413
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name:
Source Identification (SMARA, name of Pit or Job Site): SMARA 123
The fabricator's/manufacturer's product name for the sample: 0.5in X No.4 CHANGE
The fabricator/manufacturer designation for the sample:
The plant number: 005-1-3
A detailed description of where the material sample was collected: Barge
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:
