Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001178 DEA: 020J3904 EFIS: 0219000112
QA Service Level: 2
DIST-CO-RTE-PM: 02---
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Nathan Alexander Structure Rep.: Unknown
DIME Sample ID: 2025-04-22-93
TL Number from the TL Form: 823625
Sample Submitted By Organization: Atlas - Denver
Sample Organization Contact: 303-975-9959
Type of Sample: Quality Assurance
Type of Material: Asphalt Binder
Sample Taken Date: 04/22/2025
Date that the sample was received by the laboratory/organization performing the testing: 04/29/2025
The quantity of what the sample constitutes: 2 cans
A brief description of the sample: PG 58-34M
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: J F Shea Construction Inc - Fawndale Rock and Asphalt - Redding CA
Performance Grade: PG 58-34 M
Modified: Yes
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Valero Marketing & Supply - Benicia CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
