Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995263 DEA: 061G3304 EFIS: 0624000029
QA Service Level: 1
DIST-CO-RTE-PM: 06-FRE-180-118/138
Work Description: FRE 180 Emergency Slope Repairs.
Location Description:
Contractor Name: CAL VALLEY CONSTRUCTION
Contractor Address: 5125 N. Gates Ave, Ste 102, Fresno, CA 93722
Resident Engineer: Mark Mengoni Structure Rep.: Benjamin Holton
DIME Sample ID: 2023-12-15-11
TL Number from the TL Form:
Sample Submitted By Organization: CT D06 - Millbrook Field Laboratory
Sample Organization Contact: (559) 341-3953
Type of Sample: Quality Assurance
Type of Material: Aggregate
Sample Taken Date: 12/15/2023
Date that the sample was received by the laboratory/organization performing the testing: 12/15/2023
The quantity of what the sample constitutes: 9yds
A brief description of the sample: 3/8" and Sand con aggs
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Outback Fresno
Source Identification (SMARA, name of Pit or Job Site): 91-10-0005
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: Stockpile @ Plant
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 3/8 inch
The concrete mix design number: 40F5G07
Lot number:
Sublot number:
Aggregate Mix Number:
