Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001501 DEA: 040X7204 EFIS: 0424000160 COOP: 04JOC25101
QA Service Level: 1
DIST-CO-RTE-PM: 04-SON-128-12.2/24.8
Work Description: DIGOUT
Location Description: CONSTRUCTION ON STATE HIGHWAY IN SONOMA COUNTY AT AND NEAR KELLOGG FROM SAUSAL CREEK BRIDGE TO NAPA COUNTY LINE.
Contractor Name: OC Jones
Contractor Address: Unknown
Resident Engineer: Leonard Brajnikoff Structure Rep.: Unknown
DIME Sample ID: 2025-08-27-95
TL Number from the TL Form: C100600
Sample Submitted By Organization: CT D04 - Hayward DME / District Laboratory
Sample Organization Contact: (510) 507-3456
Type of Sample: Production Start-Up
Type of Material: Aggregate
Sample Taken Date: 08/27/2025
Date that the sample was received by the laboratory/organization performing the testing: 09/16/2025
The quantity of what the sample constitutes: 3 BAGS PER BIN (BIN#1-4)
A brief description of the sample: 3/4" HMA-A
From where was the sample collected: Manufacturer
Laboratory sample identification: D04-SE-25-061
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan Materials Todd Road (BP)
Source Identification (SMARA, name of Pit or Job Site): 91-49-0004
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: At the plant
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: 1
Sublot number: 3
Aggregate Mix Number: 220989
