Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 66669 DEA: JMF-DATA EFIS: JMF-DATA
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for storing JMF sample data
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2023-01-16-3
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: Crumb Rubber Modifier
Sample Taken Date: 01/16/2023
Date that the sample was received by the laboratory/organization performing the testing: 06/19/2023
The quantity of what the sample constitutes: 2 Bage
A brief description of the sample: PG 64-10
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Deer Creek Asphalt
