Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000962 DEA: 09398404 EFIS: 0924000045
QA Service Level: 1
DIST-CO-RTE-PM: 09-INY-395-T122.0/R129.5
Work Description: ASPHALTIC EMULSION (FOG SEAL COAT) & PRECOATED AGGREGATE (SEAL COAT).
Location Description: INYO COUNTY IN AND NEAR MESA FROM 0.4 MILE SOUTH OF PLEASANT VALLEY DAM ROAD TO 1.3 MILES NORTH OF GORGE ROAD
Contractor Name: AMERICAN PAVEMENT SYSTEMS, INC.
Contractor Address: Unknown
Resident Engineer: Garrett Rottner Structure Rep.: Unknown
DIME Sample ID: 2025-09-17-64
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: No Test
Type of Material: Asphalt Rubber Binder
Sample Taken Date: 09/17/2025
Date that the sample was received by the laboratory/organization performing the testing: 09/29/2025
The quantity of what the sample constitutes: 6 quart cans of rubber
A brief description of the sample: 58-22
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Centennial Asphalt
Asphalt modifier supplier:
Performance Grade: PG 58-22
Lot number:
Sublot number:
Asphalt Rubber Binder Mix Number:
