Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215393 DEA: 021J5104 EFIS: 0220000086
QA Service Level: 1
DIST-CO-RTE-PM: 02-LAS,MOD-139-57.0/66.635,0.0/0.1
Work Description: PERFORM COLD IN-PLACE RECYCLING AND PLACE HOT MIX ASPHALT (TYPE A).
Location Description: LASSEN AND MODOC COUNTIES NEAR ADIN FROM 4.5 MILES SOUTH OF COUNTY ROAD A2 TO 0.1 MILE SOUTH OF ROUTE 299
Contractor Name: Hat Creek Construction
Contractor Address: 24339 Highway 89 N, Burney, CA 96013
Resident Engineer: Mike Zdenek Structure Rep.: Unknown
DIME Sample ID: 2021-09-08-17
TL Number from the TL Form: c848967
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: 09/08/2021
Date that the sample was received by the laboratory/organization performing the testing: 09/20/2021
The quantity of what the sample constitutes: 1 can
A brief description of the sample: 58-34M
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: KLAMATH FALLS, OR
Performance Grade: PG 58-34 M
Modified: Yes
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier: CONTRACTOR HAT CREEK
Certified Asphalt Supplier: Albina Asphalt - Klamath Falls Plant - Klamath Falls OR
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
