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: 2025-10-10-37
TL Number from the TL Form:
Sample Submitted By Organization: Advantage Sealing Systems, Incorporated
Sample Organization Contact: (951) 750-2736
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: 10/10/2025
The quantity of what the sample constitutes: 1 of 1
A brief description of the sample: Tank
From where was the sample collected: Manufacturer
Laboratory sample identification: 34-101025
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Fontana CA
Performance Grade: PG 58-16
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Advantage Sealing Systems
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
