Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995257 DEA: 09401004 EFIS: 0924000007
QA Service Level: 1
DIST-CO-RTE-PM: 09-INY-190-9.8-68.0
Work Description: Emergency Repair from Flood Damage to State Route 190 near Olancha, CA.
Location Description: State Route 190
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Kris Raber Structure Rep.: Unknown
DIME Sample ID: 2023-10-17-29
TL Number from the TL Form:
Sample Submitted By Organization: CT D09 - Bishop Field Laboratory
Sample Organization Contact: (760) 872-5211
Type of Sample: Department Acceptance
Type of Material: Aggregate
Sample Taken Date: 10/17/2023
Date that the sample was received by the laboratory/organization performing the testing: 10/18/2023
The quantity of what the sample constitutes: 1 Bag of Coldfeed
A brief description of the sample: 3/4" CF
From where was the sample collected: Source
Laboratory sample identification: CF-01
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Fisher Sand and Gravel
Source Identification (SMARA, name of Pit or Job Site): 00-00-0000
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 Device at Hot 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:
