Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000824 DEA: 021K0204 EFIS: 0224000043
QA Service Level: 1
DIST-CO-RTE-PM: 02-TRI-299-53.5/61.0
Work Description: PLACE AR CHIP SEAL AND REPLACE ASPHALT CONCRETE SURFACING.
Location Description: TRINITY COUNTY IN AND NEAR WEAVERVILLE AND AT AND NEAR DOUGLAS CITY FROM 0.1 MILE WEST OF INDUSTRIAL PARKWAY TO STEEL BRIDGE ROAD
Contractor Name: AMERICAN PAVEMENT SYSTEMS, INC.
Contractor Address: Unknown
Resident Engineer: Edward Worden Structure Rep.: Unknown
DIME Sample ID: 2025-07-14-54
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Quality Assurance
Type of Material: Asphalt Binder
Sample Taken Date: 07/14/2025
Date that the sample was received by the laboratory/organization performing the testing: 07/21/2025
The quantity of what the sample constitutes: 2 cans of 58-22 binder
A brief description of the sample: PG 58-22
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Valero - Benicia, CA
Performance Grade: PG 58-22
Modified: No
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:
