Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994443 DEA: 053307C4 EFIS: 0514000028
QA Service Level: 1
DIST-CO-RTE-PM: 05-SLO-41,46-44.5/45.3,54.0/57.8
Work Description: Wye Segment - Route 41/46 Separation
Location Description:
Contractor Name: Atkinson Construction
Contractor Address: 18201 Von Karman - Suite 800, Irvine, CA 92612
Resident Engineer: Brian Harrington Structure Rep.: Dave Lewis
DIME Sample ID: 2024-07-22-86
TL Number from the TL Form:
Sample Submitted By Organization: Sequoia Consultants
Sample Organization Contact: (714) 974-6316
Type of Sample: Quality Control
Type of Material: Aggregate
Sample Taken Date: 07/22/2024
Date that the sample was received by the laboratory/organization performing the testing: 07/22/2024
The quantity of what the sample constitutes: 1 per batch
A brief description of the sample: 1x4 concrete aggregates
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Holiday Rock - Paso Robles
Source Identification (SMARA, name of Pit or Job Site): 91-42-0003
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 or belt cut
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
