Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995048 DEA: 061E5604 EFIS: 0622000066
QA Service Level: 1
DIST-CO-RTE-PM: 06-FRE-198-21.2/22.7
Work Description: Cold plane existing asphalt pavement and place RHMA.
Location Description:
Contractor Name: CAL VALLEY CONSTRUCTION
Contractor Address: 5125 N. Gates Ave, Ste 102, Fresno, CA 93722
Resident Engineer: Cary Cruz Structure Rep.: Unknown
DIME Sample ID: 2023-08-01-56
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: 08/01/2023
Date that the sample was received by the laboratory/organization performing the testing: 08/02/2023
The quantity of what the sample constitutes: 750 Tons
A brief description of the sample: 3/4 RHMA cold feed
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Granite Coalinga
Source Identification (SMARA, name of Pit or Job Site): Granite Coalinga
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: 3/4 inch
The concrete mix design number:
Lot number: 2
Sublot number: 6
Aggregate Mix Number:
