Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215310 DEA: 020J4504 EFIS: 0219000125
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS-97-0/0.0001
Work Description: DORRIS TMS
Location Description: SISKIYOU COUNTY AT AND NEAR DORRIS AT VARIOUS LOCATIONS FROM 0.3 MILE SOUTH OF RICHARDSON ROAD TO 0.1 MILE NORTH OF DORRIS BROWNWELL ROAD
Contractor Name: Roll'n Rock Construction
Contractor Address: 5527 Truck Village Drive, Mount Shasta , CA 96067
Resident Engineer: Nicole Mallory Structure Rep.: Unknown
DIME Sample ID: 2023-05-17-82
TL Number from the TL Form: 815612
Sample Submitted By Organization: CT D02 - Redding Northern Regional Laboratory
Sample Organization Contact: (530) 225-3194
Type of Sample: Production Start-Up
Type of Material: Aggregate
Sample Taken Date: 05/17/2023
Date that the sample was received by the laboratory/organization performing the testing: 05/17/2023
The quantity of what the sample constitutes: Production Start-Up Evaluation
A brief description of the sample: Laboratory-Combined Untreated Virgin Aggregate for use in 3/4-inch Type A HMA
From where was the sample collected: Manufacturer
Laboratory sample identification: D79235F
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: JF Shea Construction - Fawndale Rock and Asphalt - Redding, CA
Source Identification (SMARA, name of Pit or Job Site): 91-45-0017::Fawndale Rock Quarry - Redding, CA
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: Combined in the Laboratory from Stockpile samples
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 3/4 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
