Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001563 DEA: 020J5504 EFIS: 0219000135
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS-161-4.5/9.1
Work Description: FULL DEPTH RECYCLING-CEMENT, PLACE HMA & REPLACE INTERPRETIVE DISPLAY.
Location Description: SISKIYOU COUNTY NEAR DORRIS FROM 4.5 MILES EAST OF ROUTE 97 TO 2.1 MILES WEST OF FUGATE ROAD
Contractor Name: Rocky Mountain Construction
Contractor Address: 4815 Tingley Lane, #A, Klamath Falls, OR 97603
Resident Engineer: Austin Henry Structure Rep.: Unknown
DIME Sample ID: 2026-08-05-77
TL Number from the TL Form: 846217
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: 08/05/2026
Date that the sample was received by the laboratory/organization performing the testing: 08/28/2026
The quantity of what the sample constitutes: 2, 1 QUART CANS
A brief description of the sample: 2 CANS OF PG 58-22
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Rocky Mountain Construction - North Pit
Performance Grade: PG 58-22
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier: ROCKY MOUNTAIN CONST.- NORTH PIT
Certified Asphalt Supplier: Albina Asphalt - Klamath Falls - Klamath Falls OR
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
HMA Type: 3/4" HMA 25% RAP
HMA Supplier Mix ID Number: NOT ON TL-101
