Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215348 DEA: 060U4204 EFIS: 0616000004
QA Service Level: 1
DIST-CO-RTE-PM: 06-FRE-99-R4.9/11.6
Work Description: CONSTRUCT CRCP, PLACE HMA, AND ROADWAY EXCAVATION.
Location Description: FRESNO COUNTY IN AND NEAR SELMA AND FOWLER FROM MCCALL AVENUE UNDERCROSSING TO 0.5 MILE NORTH OF MERCED STREET UNDERCROSSING
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 3075 Townsgate Rd. Suite 200, Westlake Village CA 91361
Resident Engineer: Chris Wilfong Structure Rep.: Unknown
DIME Sample ID: 2023-07-20-20
TL Number from the TL Form:
Sample Submitted By Organization: CT D06 - Millbrook Field Laboratory
Sample Organization Contact: (559) 417-5341
Type of Sample: Department Acceptance
Type of Material: Aggregate
Sample Taken Date: 07/20/2023
Date that the sample was received by the laboratory/organization performing the testing: 07/20/2023
The quantity of what the sample constitutes: 3 bags 1x4, 3/8, sand
A brief description of the sample: concrete aggregates
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Security Paving batch plant
Source Identification (SMARA, name of Pit or Job Site): 91-10-0017
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: G322PCC291
Lot number:
Sublot number:
Aggregate Mix Number:
