Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 44444 DEA: ASCP EFIS: ASCP
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for submitting Sample information for Asphalt Supplier Certification Program.
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2025-07-29-95
TL Number from the TL Form:
Sample Submitted By Organization: Atlas - Denver
Sample Organization Contact: 303-975-9959
Type of Sample: Verification
Type of Material: Asphalt Binder
Sample Taken Date: 07/29/2025
Date that the sample was received by the laboratory/organization performing the testing: 09/08/2025
The quantity of what the sample constitutes: 2 of 2
A brief description of the sample: Tank 06
From where was the sample collected: Manufacturer
Laboratory sample identification: TK0607292025
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Mojave, CA
Performance Grade: PG 64-16
Modified:
Lot number:
Sublot number:
Tank number: 06
Time of sample: 08:30
HMA Supplier:
Certified Asphalt Supplier: Pacific Asphalt Distribution - Mojave CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
