Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000651 DEA: 010M7004 EFIS: 0123000057
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-101-109.55/125.73
Work Description: Orick Micro-Surfacing
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Ryan Dunne Structure Rep.: Unknown
DIME Sample ID: 2025-06-03-22
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - Crescent City Field Laboratory
Sample Organization Contact: (707) 496-5581
Type of Sample: Quality Assurance
Type of Material: Asphalt Binder
Sample Taken Date: 06/03/2025
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 1 Quart Can
A brief description of the sample: micro surfacing emulsion
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: VSS
Performance Grade: PG 64-16
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: VSS Emutech - Redding CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
