Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215038 DEA: 051J7804 EFIS: 0518000052
QA Service Level: 1
DIST-CO-RTE-PM: 05-SLO-101-61.88/61.88
Work Description: SAFETY IMPROVEMENTS
Location Description: WELLSONA SAFETY IMPROVEMENTS, SLO 101
Contractor Name: CALPORTLAND CONSTRUCTION
Contractor Address: 1625 East Donovan Road, Santa Maria, Ca 93456
Resident Engineer: Michael Schmidt Structure Rep.: Ye Yang
DIME Sample ID: 2026-04-02-7
TL Number from the TL Form:
Sample Submitted By Organization: CT D05 - Paso Robles Field Laboratory
Sample Organization Contact: 1 (209) 610-9363
Type of Sample: Quality Assurance
Type of Material: Aggregate
Sample Taken Date: 04/02/2026
Date that the sample was received by the laboratory/organization performing the testing: 03/19/2025
The quantity of what the sample constitutes: 750T
A brief description of the sample: AGG
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CAL PORTLAND
Source Identification (SMARA, name of Pit or Job Site): 91-40-0013
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: PLANT
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:
