Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 44444 DEA: ASCP EFIS: ASCP
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for submitting Sample information for Asphalt Supplier Certification Program.
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2025-06-26-45
TL Number from the TL Form:
Sample Submitted By Organization: Atlas - Denver
Sample Organization Contact: 303-975-9959
Type of Sample: Verification
Type of Material: Asphalt Binder
Sample Taken Date: 06/26/2025
Date that the sample was received by the laboratory/organization performing the testing: 06/26/2025
The quantity of what the sample constitutes: 2 of 2, SPLIT SAMPLE FROM SITE VISIT
A brief description of the sample: Tank 06
From where was the sample collected: Manufacturer
Laboratory sample identification: TK0806262025
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Mojave, CA
Performance Grade: PG 58-22
Modified: No
Lot number:
Sublot number:
Tank number: 8
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Pacific Asphalt Distribution - Mojave CA
Multigrade: Yes
Multigrade Type: PG 58-22 / PG 58-16
Asphalt Binder Mix Number:
