Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 44444 DEA: ASCP EFIS: ASCP
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for submitting Sample information for Asphalt Supplier Certification Program.
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2026-07-17-68
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: No Test
Type of Material: Asphalt Binder
Sample Taken Date: 07/17/2026
Date that the sample was received by the laboratory/organization performing the testing: 08/05/2026
The quantity of what the sample constitutes: 1 of 3, split sample
A brief description of the sample: Blender
From where was the sample collected: Manufacturer
Laboratory sample identification: BOL 653731
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: White City, OR
Performance Grade: PG 64-28 M
Modified: Yes
Lot number:
Sublot number:
Tank number: Rack Blend
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Western Emulsions - White City Emulsion Plant - White City OR
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
HMA Type:
HMA Supplier Mix ID Number:
