Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215425 DEA: 06360244 EFIS: 0613000005
QA Service Level: 1
DIST-CO-RTE-PM: 06-TUL-99-30.6/35.2
Work Description: Widen Freeway & Bridge Construction (Concrete Bridge)
Location Description:
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 13170 TELFAIR AVE, SYLMAR, CA, 91342
Resident Engineer: Javier Huerta Structure Rep.: Ramandeep Guraya
DIME Sample ID: 2023-09-01-100
TL Number from the TL Form:
Sample Submitted By Organization: CT D06 - Visalia Field Laboratory
Sample Organization Contact: (559) 974-1304
Type of Sample: Department Acceptance
Type of Material: Aggregate
Sample Taken Date: 09/01/2023
Date that the sample was received by the laboratory/organization performing the testing: 09/01/2023
The quantity of what the sample constitutes: 1000-500 Ton
A brief description of the sample: Class 2 Aggregate Base
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: NB Tul 99 Median J St , Windrow, J St realignment
The fabricator/manufacturer/facility name: Crushed recycled on site
Source Identification (SMARA, name of Pit or Job Site): 0613000005
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: On Job site -Windrow
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:
