Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 66666 DEA: APP EFIS: 0019000052
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for submitting Sample information for Aggregate Pre-approval Program (APP). Object Code: 1025. J2 DEA: 912680.
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2022-09-16-40
TL Number from the TL Form:
Sample Submitted By Organization: Jaxon Enterprises - Deer Creek Rock & Asphalt
Sample Organization Contact: (559) 793-0903
Type of Sample: Aggregate Prequalification Program
Type of Material: Aggregate
Sample Taken Date: 09/16/2022
Date that the sample was received by the laboratory/organization performing the testing: 09/16/2022
The quantity of what the sample constitutes: 4 buckets
A brief description of the sample: 3/8in CR
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Deer Creek Rock and Asphalt
Source Identification (SMARA, name of Pit or Job Site): 91-54-0021
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 at Plant
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 3/8 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
