Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993235 DEA: 051H4504 EFIS: 0516000075
QA Service Level: 1
DIST-CO-RTE-PM: 05-SB-154-R31.8/R32.1
Work Description: CONSTRUCT CIDH CONCRETE PILES AND STRUCTURAL CONCRETE BRIDGE.
Location Description: SANTA BARBARA COUNTY IN AND NEAR SANTA BARBARA FROM PRIMAVERA ROAD UNDERCROSSING TO LA COLINA ROAD UNDERCROSSING
Contractor Name: CA Rasmussen
Contractor Address: 28548 LIVINGSTON AVENUE, VALENICA CA 91355
Resident Engineer: Jeffery Finn Structure Rep.: Emiliano Berntsen
DIME Sample ID: 2022-06-08-42
TL Number from the TL Form:
Sample Submitted By Organization: RMA Group - Rancho Cucamonga
Sample Organization Contact: (909) 989-1751
Type of Sample: Quality Control
Type of Material: Aggregate
Sample Taken Date: 06/08/2022
Date that the sample was received by the laboratory/organization performing the testing: 06/08/2022
The quantity of what the sample constitutes: 21 CY
A brief description of the sample: Washed Concrete Sand
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CEMEX Santa Barbara
Source Identification (SMARA, name of Pit or Job Site): 91-19-0035
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: Conveyor Belt
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: fine
The concrete mix design number: 1610837
Lot number:
Sublot number:
Aggregate Mix Number:
