Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 55556 DEA: OCR EFIS: OCR
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for submitting Sample information for Oregon Corp. Research.
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2025-10-25-2
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 Binder
Sample Taken Date: 10/25/2025
Date that the sample was received by the laboratory/organization performing the testing: 10/27/2025
The quantity of what the sample constitutes: 1 can
A brief description of the sample: PG 64H-34
From where was the sample collected: Manufacturer
Laboratory sample identification: sample 366
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Ergon Asphalt and Emulsions
Performance Grade: PG 64-28
Modified: No
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Oregon Coop
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
