Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002597 DEA: 021K0404 EFIS: 0224000045
QA Service Level: 1
DIST-CO-RTE-PM: 02-SHA-273-7/11
Work Description: Happy Valley BWC
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Edward Worden Structure Rep.: Unknown
DIME Sample ID: 2026-08-24-59
TL Number from the TL Form: 857924
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 Rubber Binder
Sample Taken Date: 08/24/2026
Date that the sample was received by the laboratory/organization performing the testing: 09/01/2026
The quantity of what the sample constitutes: 2, 1 quart cans
A brief description of the sample: 2 cans of Rubberized Binder
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: JF Shea- Clear Creek
Asphalt modifier supplier: FNF Construction
Performance Grade: PG 64-16
Lot number:
Sublot number:
Asphalt Rubber Binder Mix Number:
