Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 66669 DEA: JMF-DATA EFIS: JMF-DATA
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for storing JMF sample data
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2023-02-09-12
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Hot Mix Asphalt Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Verification
Type of Material: Aggregate
Sample Taken Date: 02/09/2023
Date that the sample was received by the laboratory/organization performing the testing: 02/09/2023
The quantity of what the sample constitutes: 2
A brief description of the sample: demo
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: teichert
Source Identification (SMARA, name of Pit or Job Site): 91-01-0010
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: Bin 3/4 aggregate
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:
