*Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.

Sample Record for 2019-12-01-2


Project Information

Project ID: 66666 DEA: APP EFIS: 0019000052 QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for submitting Sample information for Aggregate Pre-approval Program (APP). Object Code: 1025. J2 DEA: 912680.
Location Description:
Contractor Name: Contractor Address:
Resident Engineer: Unknown Structure Rep.: Unknown

Sample Information

DIME Sample ID: 2019-12-01-2
TL Number from the TL Form:
Sample Submitted By Organization: Jaxon Enterprises - Deer Creek Rock & Asphalt
Sample Organization Contact: 5597930903
Type of Sample: Aggregate Prequalification Program
Type of Material: Aggregate
Sample Taken Date: 12/01/2019
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 2 buckets
A brief description of the sample: Concrete agg 3/8" Crushed
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:

Material Information

Source Identification (SMARA or name of Pit): 91-54-0021::DEER CREEK QUARRY
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: Stockpile sample by loader bucket
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:

Test Results

Test Information 4 of 4

DIME Test ID: 2019-12-01-2-4
Test Method: CTM 214-August 2010: Method of Test for Soundness of Aggregates by Use of Sodium Sulfate
Verified Date: 03/18/2020
Date Tested: 12/06/2019
Submitted By Organization: Jaxon Enterprises - Deer Creek Rock & Asphalt
Organization Address: 27671 Ave 120
Test General Comments:
Additional Comments When Verified:
Percentage Loss of material retained on 2 x 1 ½ in. sieve no data
Percentage Loss of material retained on 1 ½ x 1 in. sieve no data
Percentage Loss of material retained on 1 x ¾ in. sieve no data
Percentage Loss of material retained on ¾ x ½ in. sieve no data
Percentage Loss of material retained on ½ x ⅜ in. sieve no data
Percentage Loss of material retained on ⅜ in. x #4 sieve no data
Weighted Average Percent Loss of Coarse Aggregate 2.8 %