Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994513 DEA: 043Y0604 EFIS: 0423000193
QA Service Level: 1
DIST-CO-RTE-PM: 04-MRN-1-var/var
Work Description: PAVEMENT REPAIR
Location Description:
Contractor Name: Team Ghilotti
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2023-04-04-36
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Richmond Field Laboratory
Sample Organization Contact: (510) 231-7151
Type of Sample: Quality Assurance
Type of Material: Aggregate
Sample Taken Date: 04/04/2023
Date that the sample was received by the laboratory/organization performing the testing: 04/05/2023
The quantity of what the sample constitutes: 5 Bags
A brief description of the sample: 3/4 HMA Type A
From where was the sample collected: Manufacturer
Laboratory sample identification: Rich_23_094
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: BoDean Santa Rosa
Source Identification (SMARA, name of Pit or Job Site): 91-49-0032
The fabricator's/manufacturer's product name for the sample: 3/4 HMA Type A
The fabricator/manufacturer designation for the sample: Batch plant bins
The plant number:
A detailed description of where the material sample was collected: Bins 1, 2, 3, and 4
Where the material sample would have been placed if not sampled: Roadway
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number:
Lot number: 1
Sublot number: 5
Aggregate Mix Number: 700SPW16
