Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001219 DEA: 021J8904 EFIS: 0221000006
QA Service Level: 1
DIST-CO-RTE-PM: 02-SHA-5-R30.5/R31.0
Work Description: REPLACE PAVEMENT AND PLACE POLYESTER CONCRETE OVERLAY.
Location Description: SHASTA COUNTY NEAR O\'BRIEN FROM 0.1 MILE SOUTH OF TUNNEL GULCH VIADUCT TO THE O\'BRIEN REST AREA
Contractor Name: MCCUEN CONSTRUCTION, INC.
Contractor Address: 3269 SWETZER ROAD, Loomis CA 95650
Resident Engineer: Kyle Higgins Structure Rep.: Chris Brace
DIME Sample ID: 2025-10-15-67
TL Number from the TL Form:
Sample Submitted By Organization: G3 Quality, Incorporated - Cerritos
Sample Organization Contact: (562) 321-9840
Type of Sample: Quality Control
Type of Material: Aggregate
Sample Taken Date: 10/15/2025
Date that the sample was received by the laboratory/organization performing the testing: 10/15/2025
The quantity of what the sample constitutes: 1 bag
A brief description of the sample: 1 Inch, WCS
From where was the sample collected: Job Site
Laboratory sample identification: 80373-1 TP
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Precision Concrete Materials
Source Identification (SMARA, name of Pit or Job Site): 91-34-0053
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: Belt Cut
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1 inch
The concrete mix design number: 80373-1 TP
Lot number:
Sublot number:
Aggregate Mix Number:
