Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001113 DEA: 021K0804 EFIS: 0224000049
QA Service Level: 1
DIST-CO-RTE-PM: 02-MOD-395-0.0/5.0
Work Description: PLACE HMA OVERLAY AND REPLACE ASPHALT CONCRETE SURFACING.
Location Description: MODOC COUNTY NEAR LIKELY FROM LASSEN COUNTY LINE TO 0.8 MILE NORTH OF COUNTY ROAD 189
Contractor Name: HAT CREEK CONSTRUCTION & MATERIALS, INC.
Contractor Address: Unknown
Resident Engineer: Kyle Higgins Structure Rep.: Unknown
DIME Sample ID: 2025-10-01-53
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 Binder
Sample Taken Date: 10/01/2025
Date that the sample was received by the laboratory/organization performing the testing: 10/01/2025
The quantity of what the sample constitutes: 2cans
A brief description of the sample: PG58-34M
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Hat Creek Construction
Performance Grade: PG 58-34 M
Modified: Yes
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier: HAT CREEK CONSTRUCTION
Certified Asphalt Supplier: Albina Asphalt - Chowchilla CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
