Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213469 DEA: 024C40V4 EFIS: 0218000125
QA Service Level: 1
DIST-CO-RTE-PM: 02-SHA-5-R3.8/R11.7
Work Description: WIDEN TO 6 LANES, BRIDGE REPLACEMENT AND WIDENING AND ROADWAY REHAB
Location Description: SHASTA COUNTY IN AND NEAR ANDERSON FROM ROUTE 5/273 SEPARATION TO 0.4 MILE SOUTH OF CHURN CREEK ROAD OVERCROSSING
Contractor Name: J.F. SHEA CONSTRUCTION
Contractor Address: P.O. BOX 494519, REDDING, CA 96049-4519
Resident Engineer: Henry Benner Structure Rep.: Eric Chaffee
DIME Sample ID: 2020-01-06-3
TL Number from the TL Form:
Sample Submitted By Organization: CT - Unassigned/General Field Laboratory
Sample Organization Contact: 5625005861
Type of Sample: Department Acceptance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 01/06/2020
Date that the sample was received by the laboratory/organization performing the testing: 01/06/2020
The quantity of what the sample constitutes: 12 boxes
A brief description of the sample: 3/4” Hma
From where was the sample collected: Source
Laboratory sample identification: D78500
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: If Shea
