Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000513 DEA: 020J8504 EFIS: 0219000168
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS-89-21/R34.622
Work Description: MCCLOUD CAPM - PAVEMENT REHABILITATION
Location Description: IN SISKIYOU COUNTY AT AND NEAR MCCLOUD FROM 0.1 MILE SOUTH OF MUD CREEK BRIDGE TO ROUTE 5
Contractor Name: TULLIS, INC.
Contractor Address: Unknown
Resident Engineer: Austin Henry Structure Rep.: Unknown
DIME Sample ID: 2026-07-06-63
TL Number from the TL Form:
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 Rubber Binder
Sample Taken Date: 07/06/2026
Date that the sample was received by the laboratory/organization performing the testing: 07/15/2026
The quantity of what the sample constitutes: 2 CANS
A brief description of the sample: Asphalt Rubber Binder
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Albina - Klamath Falls, OR
Asphalt modifier supplier:
Performance Grade: PG 58-22
Lot number:
Sublot number:
Asphalt Rubber Binder Mix Number:
