Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000898 DEA: 010N8304 EFIS: 0124000116
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-96-4.9/R13.3
Work Description: PLACE RUBBER CHIP SEAL, MICRO-SURFACING, AND REPLACE AC SURFACING.
Location Description: HUMBOLDT COUNTY AT HOOPA FROM 4.6 MILES EAST OF WILLOW CREEK BRIDGE TO HOSTLER CREEK BRIDGE
Contractor Name: AMERICAN PAVEMENT SYSTEMS, INC.
Contractor Address: Unknown
Resident Engineer: Ethan Retherford Structure Rep.: Unknown
DIME Sample ID: 2025-07-22-80
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 Rubber Binder
Sample Taken Date: 07/22/2025
Date that the sample was received by the laboratory/organization performing the testing: 08/15/2025
The quantity of what the sample constitutes: 1 gallon can
A brief description of the sample: Asphalt Rubber Binder, PG 64-16 CR
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: American Pavement Systems
Asphalt modifier supplier:
Performance Grade: PG 64-16
Lot number:
Sublot number:
Asphalt Rubber Binder Mix Number:
