Sample Record for 2017-07-26-16
Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project Information
Project ID: 211852 DEA: 022H3704 EFIS: 0216000079
QA Service Level: 1
DIST-CO-RTE-PM: 02-SHA-151-0.0/5.5
Work Description: ASPHALT-RUBBER CHIP SEAL, REPLACE AC SURFACING, STRIPING
Location Description: SHASTA COUNTY IN AND NEAR SHASTA LAKE FROM SHASTA DAM TO CORAM UNDERPASS
Contractor Name: Northwest Paving
Contractor Address: 8115 Secluded Valley Dr, Redding, CA 96001
Resident Engineer: Mike Zdenek Structure Rep.: Unknown
Sample Information
DIME Sample ID: 2017-07-26-16
TL Number from the TL Form: T101 C896263
Sample Submitted By Organization: CT D02 - Redding Northern Regional Laboratory
Sample Organization Contact: (530) 225-3194
Type of Sample: Acceptance
Type of Material: Aggregate
Sample Taken Date: 07/26/2017
Date that the sample was received by the laboratory/organization performing the testing: 08/08/2017
The quantity of what the sample constitutes: 1 bags 40lbs
A brief description of the sample: 9.5mm Chips
From where was the sample collected: Manufacturer
Laboratory sample identification: D77101
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Tullis Northstate Asphalt
Material Information
Source Identification (SMARA, name of Pit or Job Site): unknown
The fabricator's/manufacturer's product name for the sample: Chips
The fabricator/manufacturer designation for the sample: Unknown
The plant number: Unknown
A detailed description of where the material sample was collected: Plant
Where the material sample would have been placed if not sampled: Unknown
Primary Aggregate Nominal Size: 3/8 inch
The concrete mix design number: Unknown
Lot number:
Sublot number:
Aggregate Mix Number:
Test Results
