FORM

DSA-202
Rev. 02/11

SIEVE ANALYSIS TEST REPORT

School District: _________________________________________ LEA #: Attn: _________________________________________ Exp. Date: Address: CA
Project Name: ________________________________ Location in Structure:_________________________ Sampled Location: By:

DSA FILE #: DSA APPL #: -

Lab Facility: Lab Doc. #:

_____________ Structure:

Lab Job #:
Report Date: ____________________________ Sample Date:

TESTING INFORMATION
Weight Retained (grams)

Sample weight before wash (g): Sample weight after wash (g): Total loss after sieving, <0.3% (%):

Sieve size
2.5 (63.5 mm) 2 1.5 1 0.75 0.5 (50 mm) (37.5 mm) (25 mm) (19 mm) (12.5 mm)

Cumulative Weight Retained (g)

% Retained Each Sieve

% Passing

Specification

0.375 (9.5 mm) No.4 No.8 (4.75 mm) (2.36 mm)

No.16 (1.18 mm) No.30 No.50 (600 m) (300 m)

No.100 (150 m) No.200 (75 m)

Applicable ASTM Test Methods: __________

__________

The Material

SAMPLED AND TESTED IN ACCORDANCE WITH THE REQUIREMENTS OF THE DSA APPROVED DOCUMENTS.
cc: Project Architect Structural Engineer Project Inspector DSA Regional Office FORM DSA-202 (rev 02/16/11) Sieve Analysis Test Report

WAS

WAS NOT

ADDITIONAL COMMENTS (DSA-211) ATTACHED.

The Material Tested

THE REQUIREMENTS OF THE DSA APPROVED DOCUMENTS.

MET DID NOT MEET

Signature Print Name / Title

PAGE 1 OF 1
CALIFORNIA DEPARTMENT OF GENERAL SERVICES

FORM

DSA-202
Rev. 02/11

SIEVE ANALYSIS TEST REPORT

School District: _________________________________________ LEA #: Attn: _________________________________________ Exp. Date: Address: CA
Project Name: ________________________________ Location in Structure:_________________________ Sampled Location: By:

DSA FILE #: DSA APPL #: -

Lab Facility: Lab Doc. #:

_____________ Structure:

Lab Job #:
Report Date: ____________________________ Sample Date:

REMARKS:

The Material

SAMPLED AND TESTED IN ACCORDANCE WITH THE REQUIREMENTS OF THE DSA APPROVED DOCUMENTS.
cc: Project Architect Structural Engineer Project Inspector DSA Regional Office FORM DSA-202 (rev 02/16/11) Sieve Analysis Test Report

WAS

WAS NOT

ADDITIONAL COMMENTS (DSA-211) ATTACHED.

The Material Tested

THE REQUIREMENTS OF THE DSA APPROVED DOCUMENTS.

MET DID NOT MEET

Signature Print Name / Title

PAGE 2 OF 1
CALIFORNIA DEPARTMENT OF GENERAL SERVICES