Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001200 DEA: 09390204 EFIS: 0921000034
QA Service Level: 1
DIST-CO-RTE-PM: 09-INY-395-57.4
Work Description: CONSTRUCT MINOR CONCRETE AND INSTALL HYBRID PEDESTRIAN BEACON.
Location Description: INYO COUNTY AT LONE PINE AT EAST MUIR STREET
Contractor Name: INTERSTATE CIVIL CONSTRUCTION
Contractor Address: PO Box 2819, Wrightwood CA 92397
Resident Engineer: Scott Eagan Structure Rep.: Unknown
DIME Sample ID: 2026-01-22-17
TL Number from the TL Form:
Sample Submitted By Organization: CT D09 - Bishop Field Laboratory
Sample Organization Contact: (760) 872-5211
Type of Sample: Quality Assurance
Type of Material: Aggregate
Sample Taken Date: 01/22/2026
Date that the sample was received by the laboratory/organization performing the testing: 01/22/2026
The quantity of what the sample constitutes: 3 Tons
A brief description of the sample: 3/4" Class 2 AB
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Grinding Rock - Independence
Source Identification (SMARA, name of Pit or Job Site): Jobsite
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: Jobsite 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:
