Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994514 DEA: 043Y0504 EFIS: 0423000192
QA Service Level: 1
DIST-CO-RTE-PM: 04-SOL-12112113-var/var
Work Description: PAVEMENT REPAIR
Location Description:
Contractor Name: OC Jones
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2023-06-27-124
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Concord Field Laboratory
Sample Organization Contact: (510) 714-7019
Type of Sample: Quality Assurance
Type of Material: Aggregate
Sample Taken Date: 06/27/2023
Date that the sample was received by the laboratory/organization performing the testing: 06/27/2023
The quantity of what the sample constitutes: N/A
A brief description of the sample: 3/4-INCH-SP Type A
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan Vallejo Batch plant
Source Identification (SMARA, name of Pit or Job Site): 91-48-0002
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: Sample Pickup From Plant
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: 411101510LB0122
