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: 2019-06-01-1
TL Number from the TL Form: AC-9101
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Verification
Type of Material: Asphalt Binder
Sample Taken Date: 06/01/2019
Date that the sample was received by the laboratory/organization performing the testing: 07/10/2019
The quantity of what the sample constitutes: ONE CAN
A brief description of the sample: TEST Asphalt Binder
From where was the sample collected: Manufacturer
Laboratory sample identification: AB195170
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: VSS Emultech
Performance Grade: PG 64-10
Modified: No
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier:
Multigrade:
Multigrade Type:
Asphalt Binder Mix Number:
