Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 333101 DEA: 03TEST04 EFIS: 03TEST3101
QA Service Level: 1
DIST-CO-RTE-PM: 03---
Work Description: THIS PROJECT WAS ADDED FOR E3101 DEVELOPMENT AND TESTING PURPOSES. DATA SUBMITTED FOR THIS PROJECT MUST NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT WAS ADDED FOR E3101 DEVELOPMENT AND TESTING PURPOSES. DATA SUBMITTED FOR THIS PROJECT MUST NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: E3101 Test Prime 34
Contractor Address: Unknown
Resident Engineer: MIchael Maksimovich Structure Rep.: Unknown
DIME Sample ID: 2025-08-06-1
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Materials Management Branch Field Office
Sample Organization Contact: (562) 500-5861
Type of Sample: Annual Source Testing
Type of Material: Asphalt Binder
Sample Taken Date: 08/06/2025
Date that the sample was received by the laboratory/organization performing the testing: 08/06/2025
The quantity of what the sample constitutes: 45
A brief description of the sample: 456
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: 654
Performance Grade: PG 58-16
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Valero Marketing & Supply - Benicia CA
Multigrade: Yes
Multigrade Type:
Asphalt Binder Mix Number:
