Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000997 DEA: 010J2104 EFIS: 0118000190
QA Service Level: 1
DIST-CO-RTE-PM: 01-DN-101-R2.6/23.9
Work Description: RHMA, HMA, AND COLD PLANE ASPHALT CONCRETE PAVEMENT.
Location Description: DEL NORTE COUNTY IN AND NEAR KLAMATH FROM 1.2 MILES SOUTH OF KLAMATH RIVER OVERFLOW TO 1.1 MILE NORTH OF HAMILTON ROAD
Contractor Name: MERCER-FRASER COMPANY
Contractor Address: P O BOX 1006, EUREKA, CA 95502-1006
Resident Engineer: Aaron Valley Structure Rep.: Joshua Erler
DIME Sample ID: 2026-04-17-20
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - Crescent City Field Laboratory
Sample Organization Contact: (707) 496-5581
Type of Sample: Quality Assurance
Type of Material: Concrete
Sample Taken Date: 04/17/2026
Date that the sample was received by the laboratory/organization performing the testing: 04/20/2026
The quantity of what the sample constitutes: 9 cy
A brief description of the sample: Barrier Transitions
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Tidewater
The concrete mix design number: Klamath Barriers
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: xx
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: xx
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
