Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000014 DEA: 010H1504 EFIS: 0117000116
QA Service Level: 1
DIST-CO-RTE-PM: 01-MEN-162-R0.0/25.7
Work Description: HMA, RHMA, AND GEOSYNTHETIC PAVEMENT INTERLAYER.
Location Description: MENDOCINO COUNTY NEAR LONGVALE FROM ROUTE 101 TO 1.1 MILES SOUTH OF POONKINNEY ROAD NEAR COVELO
Contractor Name: GRANITE CONSTRUCTION COMPANY
Contractor Address: Unknown
Resident Engineer: Steve Tisell Structure Rep.: Unknown
DIME Sample ID: 2026-04-16-34
TL Number from the TL Form: 900183
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Acceptance
Type of Material: Asphalt Binder
Sample Taken Date: 04/16/2026
Date that the sample was received by the laboratory/organization performing the testing: 04/22/2026
The quantity of what the sample constitutes: 1 can
A brief description of the sample: JMF Verification #15367
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Granite Ukiah
Performance Grade: PG 58-22
Modified:
Lot number:
Sublot number:
Tank number: JMF Verification #15367
Time of sample:
HMA Supplier: Granite Ukiah
Certified Asphalt Supplier: Valero Benicia Refinery - Benicia CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
