Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001219 DEA: 021J8904 EFIS: 0221000006
QA Service Level: 1
DIST-CO-RTE-PM: 02-SHA-5-R30.5/R31.0
Work Description: REPLACE PAVEMENT AND PLACE POLYESTER CONCRETE OVERLAY.
Location Description: SHASTA COUNTY NEAR O\'BRIEN FROM 0.1 MILE SOUTH OF TUNNEL GULCH VIADUCT TO THE O\'BRIEN REST AREA
Contractor Name: MCCUEN CONSTRUCTION, INC.
Contractor Address: 3269 SWETZER ROAD, Loomis CA 95650
Resident Engineer: Kyle Higgins Structure Rep.: Chris Brace
DIME Sample ID: 2025-08-22-46
TL Number from the TL Form: 866072
Sample Submitted By Organization: CT D02 - Redding Northern Regional Laboratory
Sample Organization Contact: (530) 225-3194
Type of Sample: Acceptance
Type of Material: Aggregate
Sample Taken Date: 08/22/2025
Date that the sample was received by the laboratory/organization performing the testing: 08/25/2025
The quantity of what the sample constitutes: Stockpile
A brief description of the sample: Class 2 Aggregate Base
From where was the sample collected: Distributor
Laboratory sample identification: D80018
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Tullis – Crystal Creek Aggregates (Redding, CA)
Source Identification (SMARA, name of Pit or Job Site): 91-45-0021
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
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
