Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994751 DEA: 010C5004 EFIS: 0112000292
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-36-11.3/34.6
Work Description: Project Name: Bridge Rail Replacement - 3 Bridges
Location Description: Hely Creek, Little Larabee Creek and Butte Creek Bridge.
Contractor Name: Mercer-Fraser Company
Contractor Address: 200 Dinsmore Dr, Fortuna, CA 95540
Resident Engineer: Joaquin Rodriguez Structure Rep.: Shantanu Nalawade
DIME Sample ID: 2023-11-10-63
TL Number from the TL Form: 930385
Sample Submitted By Organization: CT D01 - District 1 Materials Laboratory
Sample Organization Contact: (707) 496-0974
Type of Sample: Verification
Type of Material: Asphalt Binder
Sample Taken Date: 11/10/2023
Date that the sample was received by the laboratory/organization performing the testing: 12/22/2023
The quantity of what the sample constitutes: 1 can RHMA
A brief description of the sample: 1/2" RHMA-G - Paving
From where was the sample collected: Supplier
Laboratory sample identification: 23-339
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Mercer Fraser Boyd Road
Performance Grade: PG 64-16
Modified: No
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Valero Marketing & Supply - Benicia CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
