Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995538 DEA: 024H0604 EFIS: 0218000073
QA Service Level: 1
DIST-CO-RTE-PM: 02-PLU,PLU-36-
Work Description: CHESTER CAUSEWAY REHAB
Location Description: LASSEN AND PLUMAS COUNTIES FROM MELISSA AVENUE TO 0.6 MILE EAST OF RED RIVER CANAL
Contractor Name: HAT CREEK CONSTRUCTION & MATERIALS, INC.
Contractor Address: Unknown
Resident Engineer: Daniel Gibbs Structure Rep.: Unknown
DIME Sample ID: 2025-07-21-21
TL Number from the TL Form: c867342
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: 07/21/2025
Date that the sample was received by the laboratory/organization performing the testing: 07/25/2025
The quantity of what the sample constitutes: 2 cans
A brief description of the sample: Binder PG 58-34 Non-Modified
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Albina - Klamath Falls, OR
Performance Grade: PG 58-34
Modified: No
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Albina Asphalt (Klamath Falls Plant) - Klamath Falls OR
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
