Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
DEA: No Project
QA Service Level:
DIST-CO-RTE-PM: ---
Work Description: Special project identifier for material not associated with a project
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2023-08-01-36
TL Number from the TL Form:
Sample Submitted By Organization: Alta Vista Solutions - Whittier
Sample Organization Contact: (510) 542-9827
Type of Sample: Quality Assurance
Type of Material: Aggregate
Sample Taken Date: 08/01/2023
Date that the sample was received by the laboratory/organization performing the testing: 08/01/2023
The quantity of what the sample constitutes: 1500 sq yds.
A brief description of the sample: Class 3 Agg BAse
From where was the sample collected: Job Site
Laboratory sample identification: 9999
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: n/a
Source Identification (SMARA, name of Pit or Job Site): n/a
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: CTM 231 holes
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:
