Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000859 DEA: 033H9104 EFIS: 0318000086
QA Service Level: 1
DIST-CO-RTE-PM: 03-NEV-80-0.1/0.1
Work Description: Kingvale Back up Generator
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2026-04-17-22
TL Number from the TL Form:
Sample Submitted By Organization: Mozamo Engineering, Incorporated
Sample Organization Contact: (916) 237-7161
Type of Sample: Quality Assurance
Type of Material: Asphalt Rubber Binder
Sample Taken Date: 04/17/2026
Date that the sample was received by the laboratory/organization performing the testing: 04/20/2026
The quantity of what the sample constitutes: Daily Production
A brief description of the sample: Rubber Binder PG-64-16
From where was the sample collected: Distributor
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: De Silva Gates - Marysville
Asphalt modifier supplier: De Silva Gates
Performance Grade: PG 64-16
Lot number: 1
Sublot number: 1
Asphalt Rubber Binder Mix Number: MD 6617
