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: 2025-10-10-29
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: 10/10/2025
Date that the sample was received by the laboratory/organization performing the testing: 10/20/2025
The quantity of what the sample constitutes: 2 of 2
A brief description of the sample: Tank 868
From where was the sample collected: Manufacturer
Laboratory sample identification: AC-3262-WS
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: West Sacramento,CA
Performance Grade: PG 64-28
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: VSS Emultech - West Sacramento CA
Multigrade: No
Multigrade Type: PG 64-28 / PG 64-16 / PG 64-10
Asphalt Binder Mix Number:
