Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215180 DEA: 060Q9204 EFIS: 0614000010 COOP: 061764
QA Service Level: 1
DIST-CO-RTE-PM: 06-KER-99-10.4/21.2
Work Description: CONSTRUCT CRCP AND HMA (TYPE A) PAVEMENT.
Location Description: KERN COUNTY IN AND NEAR BAKERSFIELD FROM 0.4 MILE SOUTH OF OLD US 99 OVERCROSSING TO 0.1 MILE NORTH OF WHITE LANE OVERCROSSING
Contractor Name: Griffith Company
Contractor Address: 1128 Carrier Parkway, Bakersfield ,CA 93308
Resident Engineer: James Burford Structure Rep.: Ulysis Baal
DIME Sample ID: 2023-06-22-1
TL Number from the TL Form:
Sample Submitted By Organization: CT D06 - Bakersfield Field Laboratory
Sample Organization Contact: 661-549-8281
Type of Sample: Department Acceptance
Type of Material: Aggregate
Sample Taken Date: 06/22/2023
Date that the sample was received by the laboratory/organization performing the testing: 06/22/2023
The quantity of what the sample constitutes: 2 bags of aggregate 1 bag sand
A brief description of the sample: CRCP Aggregates
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Hwy 223 off ramp sb 99
Source Identification (SMARA, name of Pit or Job Site): 91-15-0068
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: Conveyor Belt
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1 inch
The concrete mix design number: G3-21-PCC-263
Lot number:
Sublot number:
Aggregate Mix Number:
