Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994401 DEA: 09379304 EFIS: 0919000007
QA Service Level: 1
DIST-CO-RTE-PM: 09-INY-127-21.0/34.5,41.8/49.4
Work Description: PARTIAL DEPTH RECYCLE AND HOT MIX ASPHALT (TYPE A).
Location Description: INYO COUNTY NEAR SHOSHONE FROM 4.6 MILES NORTH OF ROUTE 178 WEST TO 7.6 MILES SOUTH OF ROUTE 190 AND FROM 0.3 MILE SOUTH OF ROUTE 190 TO NEVADA STATE LINE
Contractor Name: HAT CREEK CONSTRUCTION & MATERIALS INC.
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2023-04-03-60
TL Number from the TL Form:
Sample Submitted By Organization: CT D09 - Bishop Field Laboratory
Sample Organization Contact: (760) 872-5211
Type of Sample: Verification
Type of Material: Aggregate
Sample Taken Date: 04/03/2023
Date that the sample was received by the laboratory/organization performing the testing: 04/03/2023
The quantity of what the sample constitutes: 2 Bags of Coldfedd & 1 Bag of RAP
A brief description of the sample: 3/4" Type A Aggregates
From where was the sample collected: Manufacturer
Laboratory sample identification: JMF-01
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Wulfenstein Construction
Source Identification (SMARA, name of Pit or Job Site): 99-99-9999
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: Sample Device at Wulfenstein Plant
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:
