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: 2025-09-15-71
TL Number from the TL Form:
Sample Submitted By Organization: CT D03 - Olivehurst Northern Regional Laboratory
Sample Organization Contact: (530) 741-4238
Type of Sample: Verification
Type of Material: Asphalt Rubber Binder
Sample Taken Date: 09/15/2025
Date that the sample was received by the laboratory/organization performing the testing: 09/16/2025
The quantity of what the sample constitutes: Cans of Binder
A brief description of the sample: PG64-16 PNW
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Pacific North West
Asphalt modifier supplier:
Performance Grade: PG 64-16
Lot number:
Sublot number:
Asphalt Rubber Binder Mix Number:
