SOURCE APPROVAL OF COARSE AGGREGATE

FOR PCC, GRAVEL

PART I:  (PRODUCER REQUEST)

Producer:        Source Name: 

Location:    Sec    Twp   Rng    County: 

Durability Class Requested: 

By:       Date: 

PART II:  (SOURCE DESCRIPTION - By Producer)

Overburden:    Production Depth:   Above Water: 

PART III:  (DISTRICT RECOMMENDATIONS)

By:       Date: 

PART IV:  (CENTRAL OFFICE DETERMINATION)

Preliminary Approval:      Date: 

Final Approval:        Date: 

Durability Class:         T203 Code No.:

DATA SHEET

(GRAVELS)

1.   DESCRIPTION OF SOURCE AND PRODUCTION METHODS:

2.   PETROGRAPHIC ANALYSIS:

Ls & Dol             Dk Ig              Lt Ig             Qtz              Chert           Sh           FeO           Other

%

3.   PRODUCTION TESTS:

Lab #              'A'              Abr              SpGr            Abs             PI               DF            Remarks

4.   SERVICE RECORD:

Project Number                   Year                  County               Rte              MP            Condition

5.   SIMILAR SOURCES:

6.   OTHER TESTS: