Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 66669 DEA: JMF-DATA EFIS: JMF-DATA
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for storing JMF sample data
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2025-07-09-109
TL Number from the TL Form:
Sample Submitted By Organization: CT D02 - Redding Northern Regional Laboratory
Sample Organization Contact: (530) 225-3194
Type of Sample: Verification
Type of Material: Asphalt Binder
Sample Taken Date: 07/09/2025
Date that the sample was received by the laboratory/organization performing the testing: 07/09/2025
The quantity of what the sample constitutes: JMF Verification
A brief description of the sample: 2 cans of PG 58-34
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Albina — Klamath Falls, OR
Performance Grade: PG 58-34
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier:
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
