Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1212 DEA: 033M4404 EFIS: 0300000571
QA Service Level: 1
DIST-CO-RTE-PM: 03-YOL-5-.01
Work Description: REPAIR TE FENDER DOLPHIN SYSTEM AT THE SACRAMENTO RIVER BRIDGE
Location Description:
Contractor Name: GOLDEN STATE BRIDGE INC.
Contractor Address: Unknown
Resident Engineer: Brent Bullard Structure Rep.: Brent Bullard
DIME Sample ID: 2025-07-01-2
TL Number from the TL Form:
Sample Submitted By Organization: PNAC LLC
Sample Organization Contact: (775) 835-6366
Type of Sample: Quality Control
Type of Material: Asphalt Binder
Sample Taken Date: 07/01/2025
Date that the sample was received by the laboratory/organization performing the testing: 07/01/2025
The quantity of what the sample constitutes: 1 qt can
A brief description of the sample: Asphalt Binder Sample
From where was the sample collected: Supplier
Laboratory sample identification: 2025-07-01
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: PNAC LLC, Marathon Petroleum
Performance Grade: PG 64-28
Modified: No
Lot number:
Sublot number:
Tank number: 12
Time of sample: 0500
HMA Supplier:
Certified Asphalt Supplier: Paramount Nevada Asphalt(PNAC) LLC - Fernley NV
Multigrade: Yes
Multigrade Type: PG 64-28 / PG 64-16 / PG 64-10
Asphalt Binder Mix Number:
