Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001288 DEA: 041X1004 EFIS: 0424000249
QA Service Level: 1
DIST-CO-RTE-PM: 04-SCL-9-4.0
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Gene Earl Malonzo Structure Rep.: Unknown
DIME Sample ID: 2025-07-21-78
TL Number from the TL Form: SJ-072125-2
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: 07/21/2025
Date that the sample was received by the laboratory/organization performing the testing: 10/30/2025
The quantity of what the sample constitutes: 4 bags Aggregate
A brief description of the sample: 1/2" HMA-A+15% RAP
From where was the sample collected: Manufacturer
Laboratory sample identification: D04-SE-25-076
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Peninsula Road Materials-RC
Source Identification (SMARA, name of Pit or Job Site): 91-35-0012
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: Conveyer Belt-HMA Plant
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: 373
