Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215350 DEA: 081E0604 EFIS: 0813000140
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-18-97.0/99.5
Work Description: WIDEN ROADWAY WITH HMA, MINOR CONCRETE & MODIFY SIGNAL & LIGHTING.
Location Description: SAN BERNARDINO COUNTY IN VICTORVILLE FROM AMARGOSA ROAD TO COBALT ROAD
Contractor Name: SULLY-MILLER CONTRACTING COMPANY
Contractor Address: 135 S STATE COLLEGE BLVD #400, BREA CA 92821
Resident Engineer: Larry Canuti Structure Rep.: Unknown
DIME Sample ID: 2021-10-11-36
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Barstow Field Laboratory 1
Sample Organization Contact: (760) 252-9216
Type of Sample: Quality Assurance
Type of Material: Aggregate
Sample Taken Date: 10/11/2021
Date that the sample was received by the laboratory/organization performing the testing: 10/12/2021
The quantity of what the sample constitutes: 1Bag
A brief description of the sample: 1 x 4 PCC Aggregate
From where was the sample collected: Manufacturer
Laboratory sample identification: beta test 01 of 10cy out at 1304
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: robertson adlanto
Source Identification (SMARA, name of Pit or Job Site): 91-36-0116
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: At the plant
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1-1/2 inch
The concrete mix design number: SC505B38
Lot number:
Sublot number:
Aggregate Mix Number:
