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Engineering Materials Lab -
Sample Submittal Form
For your protection and reference, please complete form as fully as possible.
Job Name:
Lab No.:
Job Number:
Work Order:
"A" Number:
Inspector:
Prime Contractor:
Sample Location:
Latitude
Longtitude
Supplier:
Depth/Thickness:
Plant:
Sampled by:
Product Code:
Data Sampled:
Ticket No.:
Time Sampled:
Temp:
Date Recvd. by Lab
Logged in by:
Type of Material
(check one)
SG
A12.5
Rubber
TBF
A19
Select
ABC
R12.5
Chips
Millings
R19
Other
Indicate Tests to be Completed
(check all that apply)
Proctor
Burn-off & Gradation
Sand Equivalent
Sieve Analysis
Rice
Hydrometer
P.I. (Dry Prep)
Marshall
Shrinkage
P.I. (Wet Prep)
Gyratory
Fractured Faces
Moisture
UVC
Lime Check
Specific Gravity
Stability & Flow
Other
Sample Location
(check all that apply)
Stockpile
Trench
Roadway
Other
Comments:
Copyright 2007 City of Mesa
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