Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001276 DEA: 043X1004 EFIS: 0425000198
QA Service Level: 1
DIST-CO-RTE-PM: 04-SON--36.36
Work Description: 3X100 REPAIR SLIPOUT AT STILWATER COVE
Location Description: Son-001-PM36.36
Contractor Name: PRECISION GRADE, INC. (Christian Robertson)
Contractor Address: 129 N. Cloverdale Blvd. #7, Cloverdale, CA 95425
Resident Engineer: Harley Paulo Structure Rep.: Unknown
DIME Sample ID: 2026-03-24-28
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Richmond Field Laboratory
Sample Organization Contact: (510) 231-7151
Type of Sample: Quality Assurance
Type of Material: Aggregate
Sample Taken Date: 03/24/2026
Date that the sample was received by the laboratory/organization performing the testing: 03/24/2026
The quantity of what the sample constitutes: 1 bag
A brief description of the sample: Class 2 AB
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Canyon Rock
Source Identification (SMARA, name of Pit or Job Site): 91-37-0024
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: 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:
