Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001025 DEA: 023J3304 EFIS: 0222000035
QA Service Level: 1
DIST-CO-RTE-PM: 02-SHA,TEH-5,44,273-Var
Work Description: FURNISH AND PLACE POLYESTER CONCRETE OVERLAY AND REPLACE JOINT SEALS.
Location Description: SHASTA AND TEHAMA COUNTIES AT VARIOUS LOCATIONS
Contractor Name: MCCUEN CONSTRUCTION, INC.
Contractor Address: 3132 thunder valley ct. ste 300, lincoln CA 95648
Resident Engineer: Nathan Alexander Structure Rep.: Chris Brace
DIME Sample ID: 2026-06-23-49
TL Number from the TL Form:
Sample Submitted By Organization: Atlas - Denver
Sample Organization Contact: 303-975-9959
Type of Sample: Quality Assurance
Type of Material: Asphalt Binder
Sample Taken Date: 06/23/2026
Date that the sample was received by the laboratory/organization performing the testing: 07/01/2026
The quantity of what the sample constitutes: 2 CANS OF BINDER
A brief description of the sample: 58-22
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: JF Shea Fawndale
Performance Grade: PG 58-22
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier: JF Shea - Fawndale
Certified Asphalt Supplier: Albina Asphalt - Klamath Falls - Klamath Falls OR
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
