Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215620 DEA: 01436404 EFIS: 0100000193
QA Service Level: 1
DIST-CO-RTE-PM: 01-DN-101-35.8/36.5
Work Description: Dr. Fine Bridge Replacement
Location Description: DR. FINE BRIDGE REPLACEMENT FROM LAKE EARL DR TO S FRED D. HAIGHT DR ON HWY 101 ACROSS SMITH RIVER.
Contractor Name: MCM Construction
Contractor Address: PO Box 620, North Highlands, Ca 95660
Resident Engineer: Clayton Malmberg Structure Rep.: Brian Cinkutis
DIME Sample ID: 2025-09-12-7
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: 09/12/2025
Date that the sample was received by the laboratory/organization performing the testing: 09/12/2025
The quantity of what the sample constitutes: 4 bags of aggregate
A brief description of the sample: 3/4" agg, 3/8" pea gravel, fine sand, coarse sand
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier: 01-0020
Structure name: Dr Fine Bridge
The fabricator/manufacturer/facility name: Tidewater Bar Plant
Source Identification (SMARA, name of Pit or Job Site): Tidewater Bar Plant
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: from stockpiles @ Tidewater Bar Plant
Where the material sample would have been placed if not sampled: Span 1 & 2 soffit/stems
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number: SR Structure
Lot number:
Sublot number:
Aggregate Mix Number:
