Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 209520 DEA: 06470904 EFIS: 0600000973 COOP: 061529
QA Service Level: 1
DIST-CO-RTE-PM: 06-MAD-99-R7.5/15.1
Work Description: WIDEN FREEWAY FROM 4 LANES TO 6 LANES.
Location Description: MADERA COUNTY IN AND NEAR MADERA FROM AVENUE 12 OVERCROSSING TO 0.9 MILE NORTH OF AVENUE 17 OVERCROSSING
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 13170 TELFAIR AVENUE, SYLMAR CA 91342
Resident Engineer: Eric Karlson Structure Rep.: Peter Moua
DIME Sample ID: 2020-08-17-33
TL Number from the TL Form: 816117
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Department Acceptance
Type of Material: Asphalt Binder
Sample Taken Date: 08/17/2020
Date that the sample was received by the laboratory/organization performing the testing: 09/03/2020
The quantity of what the sample constitutes: 1 can, NO TEST #23, #24(057043)
A brief description of the sample: Asphalt Binder PG 70-10
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: vulcan madera
Performance Grade: PG 70-10
Modified: No
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier:
Multigrade:
Multigrade Type:
Asphalt Binder Mix Number:
