Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212246 DEA: 053307A4 EFIS: 0514000027
QA Service Level: 1
DIST-CO-RTE-PM: 05-SLO-46-49.7/54.6
Work Description: Cholame Segment
Location Description:
Contractor Name: Atkinson Construction
Contractor Address: 18201 Von Karman - Suite 800, Irvine, CA 92612
Resident Engineer: Andrew Borrelli Structure Rep.: Dave Lewis
DIME Sample ID: 2022-07-12-8
TL Number from the TL Form:
Sample Submitted By Organization: CT D05 - Whitley Gardens Field Laboratory
Sample Organization Contact: 805-540-9933
Type of Sample: Quality Assurance
Type of Material: Aggregate
Sample Taken Date: 07/12/2022
Date that the sample was received by the laboratory/organization performing the testing: 07/12/2022
The quantity of what the sample constitutes: Structure Backfill Stockpile
A brief description of the sample: Fill Sand from SPM
From where was the sample collected: Job Site
Laboratory sample identification: 37044structure backfill gradation
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Sierra Pacific - Avenal
Source Identification (SMARA, name of Pit or Job Site): 91-10-0006
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: Jobsite mixed stockpile
Where the material sample would have been placed if not sampled: Bridge Abutment
Primary Aggregate Nominal Size: 1/2 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
