Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
DEA: No Project
QA Service Level:
DIST-CO-RTE-PM: ---
Work Description: Special project identifier for material not associated with a project
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2026-07-01-52
TL Number from the TL Form: 666666
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Production Start-Up
Type of Material: Asphalt Binder
Sample Taken Date: 07/01/2026
Date that the sample was received by the laboratory/organization performing the testing: 07/07/2026
The quantity of what the sample constitutes: 3/4" HMA-A R25 PG 64-16
A brief description of the sample: 2, 1 quart cans
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Teichert Woodland
Performance Grade: PG 64-16
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier: TEICHERT WOODLAND
Certified Asphalt Supplier: Pacific Northwest Oil - Stockton CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
HMA Type:
HMA Supplier Mix ID Number:
