Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002671 DEA: 09402704 EFIS: 0924000060
QA Service Level: 1
DIST-CO-RTE-PM: 09-MNO--unknown
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2026-09-17-63
TL Number from the TL Form:
Sample Submitted By Organization: CT D09 - Bishop Field Laboratory
Sample Organization Contact: (760) 872-5211
Type of Sample: Quality Assurance
Type of Material: Aggregate
Sample Taken Date: 09/17/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: Daily Production
A brief description of the sample: 3/8's Chip
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Road and Highway Builders
Source Identification (SMARA, name of Pit or Job Site): Job Site
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 @ Plant
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 3/8 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
