Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994971 DEA: 061E6204 EFIS: 0622000069
QA Service Level: 1
DIST-CO-RTE-PM: 06-TUL-198-R19.7/26.7, 1.0/13.9
Work Description:
Location Description:
Contractor Name: PAVEMENT COATINGS CO.
Contractor Address: 19062 San Jose Avenue, LaPuente,CA 91748
Resident Engineer: Haidar Haddadin Structure Rep.: Unknown
DIME Sample ID: 2023-08-23-63
TL Number from the TL Form: 0000
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Quality Assurance
Type of Material: Asphalt Binder
Sample Taken Date: 08/23/2023
Date that the sample was received by the laboratory/organization performing the testing: 08/23/2023
The quantity of what the sample constitutes: 1 Can
A brief description of the sample: binder can
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: San Joaquin Refinery
Performance Grade: PG 70-10
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: San Joaquin Refinery - Bakersfield CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
