Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 44444 DEA: ASCP EFIS: ASCP
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for submitting Sample information for Asphalt Supplier Certification Program.
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2021-11-11-32
TL Number from the TL Form:
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: 11/11/2021
Date that the sample was received by the laboratory/organization performing the testing: 12/17/2021
The quantity of what the sample constitutes: 1 of 3
A brief description of the sample: 6
From where was the sample collected: Manufacturer
Laboratory sample identification: 111121-6
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Mojave, CA.
Performance Grade: PG 64-16
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Western Emulsions - White City Emulsion Plant - White City OR
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
