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: 2025-12-18-17
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Richmond Field Laboratory
Sample Organization Contact: (510) 231-7151
Type of Sample: Acceptance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 12/18/2025
Date that the sample was received by the laboratory/organization performing the testing: 12/18/2025
The quantity of what the sample constitutes: 4 boxes
A brief description of the sample: RHMA-G
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Doe Plant
