Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002310 DEA: 010P6404 EFIS: 0125000053
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-101-R131.7/134.6
Work Description: Boyes Creek Viaduct
Location Description:
Contractor Name: GR Sundberg Inc
Contractor Address: 5211 Boyd Road, Arcata CA, 95521
Resident Engineer: Ryan Dunne Structure Rep.: Unknown
DIME Sample ID: 2026-06-12-3
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - Boyd Road Field Laboratory
Sample Organization Contact: (707) 496-0974
Type of Sample: Quality Assurance
Type of Material: Asphalt Rubber Binder
Sample Taken Date: 06/12/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/12/2026
The quantity of what the sample constitutes: 1 QT
A brief description of the sample: PG 64-16
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Mercer Fraser Boyd Road
Asphalt modifier supplier:
Performance Grade: PG 64-16
Lot number:
Sublot number:
Asphalt Rubber Binder Mix Number:
