Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 211450 DEA: 033F3604 EFIS: 0312000216
QA Service Level: 1
DIST-CO-RTE-PM: 03---
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2022-11-22-33
TL Number from the TL Form:
Sample Submitted By Organization: Con-Fab California, LLC
Sample Organization Contact: (661) 630-7162
Type of Sample: Quality Control
Type of Material: Aggregate
Sample Taken Date: 11/22/2022
Date that the sample was received by the laboratory/organization performing the testing: 11/21/2022
The quantity of what the sample constitutes: 1018 grams
A brief description of the sample: 3/8
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Granite Arvin CA
Source Identification (SMARA, name of Pit or Job Site): SMARA 91-15-0114
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: silo
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:
