Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212496 DEA: 024E4504 EFIS: 0200020286
QA Service Level: 1
DIST-CO-RTE-PM: 02-LAS,MOD-139,299-VAR
Work Description: PLACE HMA, REPLACE DRAINAGE, CULVERT, ELECTRICAL AND LIGHTING SYSTEMS.
Location Description: LASSEN AND MODOC COUNTIES ON ROUTE 139 AT 0.1 MILE NORTH OF LASSEN COUNTY LINE AND ON ROUTE 299 AT VARIOUS LOCATONS FROM 0.4 MILE WEST OF BOYD HILL LOOKOUT ROAD TO 0.6 MILE EAST OF COUNTY ROAD 87
Contractor Name: PAR ELECTRICAL CONTRACTORS INC
Contractor Address: 1465 WEST FOURTH STREET, RENO, NV 89503
Resident Engineer: Mike Zdenek Structure Rep.: Chris Brace
DIME Sample ID: 2021-08-24-32
TL Number from the TL Form: 854931
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: 08/24/2021
Date that the sample was received by the laboratory/organization performing the testing: 08/31/2021
The quantity of what the sample constitutes: 2 cans
A brief description of the sample: Asphalt Binder PG 58-34M
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Albina Asphalt - Klamath FAlls, OR
Performance Grade: PG 58-34 M
Modified: Yes
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Albina Asphalt - Klamath Falls Plant - Klamath Falls OR
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
