Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 66669 DEA: JMF-DATA EFIS: JMF-DATA
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for storing JMF sample data
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2025-05-05-86
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Hayward DME / District Laboratory
Sample Organization Contact: (510) 507-3456
Type of Sample: Verification
Type of Material: Asphalt Binder
Sample Taken Date: 05/05/2025
Date that the sample was received by the laboratory/organization performing the testing: 05/05/2025
The quantity of what the sample constitutes: 2 Cans
A brief description of the sample: PG64-16 (CRM)
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Dutra Materials - Richmond
Performance Grade: PG 64-16
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier:
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
