fs# = (contract id-seq.#) colorado … · field report for sample identification ... field...
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CDOT Form #157 3/18Previous editions are obsolete and may not be used.Distribution:
COLORADO DEPARTMENT OF TRANSPORTATIONFIELD REPORT FOR SAMPLE IDENTIFICATIONOR MATERIALS DOCUMENTATION
Region
Contract ID Date Submitted
Project No.
Project Location
Material Code (LIMS) Special Provisions yes
Previously used on Project No.: Previous CDOT Form #157 F/S No.(s): CDOT Form #633 (sack) CDOT Form #634 (can)
Sample Identification: Quantity & Unit of material submitted, describe tests required, precise location sample remove from (Stationing). etc. Materials Documentation: Field inspected (describe appearance, weight/dimensions, model/serial number), COC &/or CTR provided etc.
Date neededPreliminary Construction Maintenance Emergency
Contractor Supplier
Pit name or ownerSampled from(Pit, roadway, windrow,stock, etc.)
Quantity represented Previous quantity Total quantity to date
DateViaSample submitted:
Yes NoShipped specified quantity to:
Central lab Region labSampled or inspected by
Supervisor Title Residency
Field Lab phone
(print name) Title E-mail
(Pro./Res./Matls. Engr./Maint. Supt.) (print name)
APL/QML Acceptance: APL Ref. No.
APL/QML Acceptance: APL Ref. No.
Product name:
Product name:
Date checked:
Date checked:
Material Type
Item Class Grading
Sample ID (#1) Sample ID (#2) Sample ID (#3)
Sample ID (#4) Sample ID (#5) Sample ID (#6)
Cell Phone
FS# = (Contract ID-Seq.#)
Central Lab use only:
Chemical Lab: [email protected] Lab: [email protected] Flexible Pavement: [email protected] Physical Properties: [email protected] Lab: [email protected] Labs: Send completed form with sample Project File: SMM – Upload completed form into the attachment icon on the sample record