Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002310 DEA: 010P6404 EFIS: 0125000053
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-101-R131.7/134.6
Work Description: Boyes Creek Viaduct
Location Description:
Contractor Name: GR Sundberg Inc
Contractor Address: 5211 Boyd Road, Arcata CA, 95521
Resident Engineer: Ryan Dunne Structure Rep.: Unknown
DIME Sample ID: 2026-06-10-29
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: Aggregate
Sample Taken Date: 06/10/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 2 bags
A brief description of the sample: cold feed
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Mercer Fraser Boyd Road
Source Identification (SMARA, name of Pit or Job Site): 91-12-0010
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: discharge from belt before dryer
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1/2 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
