Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993835 DEA: 033F0734 EFIS: 0322000011
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-51-2.0/3.5
Work Description: Dredge, construct in-water foundation
Location Description:
Contractor Name: American River Constructors
Contractor Address: 4001 Bradshaw Road, Sacramento, CA 95827
Resident Engineer: John Ruzic Structure Rep.: Luis Guzman
DIME Sample ID: 2023-05-11-30
TL Number from the TL Form:
Sample Submitted By Organization: Blackburn Consulting
Sample Organization Contact: (916) 375-8706
Type of Sample: Quality Control
Type of Material: Aggregate
Sample Taken Date: 05/11/2023
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 1 Bag
A brief description of the sample: Class 2 Aggregate Base
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Bell Marine Industrial Aggregates
Source Identification (SMARA, name of Pit or 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 under conveyor belt
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:
