Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993578 DEA: 112N1174 EFIS: 1121000146
QA Service Level: 1
DIST-CO-RTE-PM: 11-SD-8-R0.7/2.9
Work Description: PLACE RHMA-G (BONDED WEARING COURSE) AND PAVEMENT DELINEATION.
Location Description: SAN DIEGO COUNTY IN SAN DIEGO FROM 0.3 MILE EAST OF MORENA BOULEVARD UNDERCROSSING TO 0.1 MILE WEST OF MISSION CENTER ROAD OVERCROSSING
Contractor Name: HAZARD CONSTRUCTION
Contractor Address: 10529 Vine Street, Lakeside, CA 92040
Resident Engineer: Ben Haney Structure Rep.: Unknown
DIME Sample ID: 2022-10-28-40
TL Number from the TL Form: C003308
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Department Acceptance
Type of Material: Asphalt Binder
Sample Taken Date: 10/28/2022
Date that the sample was received by the laboratory/organization performing the testing: 11/09/2022
The quantity of what the sample constitutes: 1 Quart Can
A brief description of the sample: PG Asphalt Binder
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Coachella
Performance Grade: PG 70-10
Modified: No
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Lunday Thagard Company-World Oil - South Gate CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
