Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 2720 DEA: 050N7204 EFIS: 0500000227 MINOR: 05A1245
QA Service Level: 1
DIST-CO-RTE-PM: 05---
Work Description:
Location Description:
Contractor Name: Robert J Frank Construction
Contractor Address: 2806 Tarmac Road, Redding, CA 96003
Resident Engineer: CHARLES HENCH Structure Rep.: Unknown
DIME Sample ID: 2023-12-01-6
TL Number from the TL Form:
Sample Submitted By Organization: CT D05 - Carpinteria Field Laboratory
Sample Organization Contact: (805) 621-3616
Type of Sample: Quality Assurance
Type of Material: Aggregate
Sample Taken Date: 12/01/2023
Date that the sample was received by the laboratory/organization performing the testing: 12/01/2023
The quantity of what the sample constitutes: 9 cy
A brief description of the sample: 1x4 PCC Aggregates
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: CEMEX Santa Barbara
Source Identification (SMARA, name of Pit or Job Site): Hi-Grade Materials Little Rock
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: South Padero Rd
Where the material sample would have been placed if not sampled:
Primary Aggregate Nominal Size: 1 inch
The concrete mix design number:
Lot number:
Sublot number:
Aggregate Mix Number:
