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.: Ryan Duran
DIME Sample ID: 2024-04-08-8
TL Number from the TL Form: 827377
Sample Submitted By Organization: CT D01 - District 1 Materials Laboratory
Sample Organization Contact: (707) 496-0974
Type of Sample: Department Acceptance
Type of Material: Asphalt Binder
Sample Taken Date: 04/08/2024
Date that the sample was received by the laboratory/organization performing the testing: 04/08/2024
The quantity of what the sample constitutes: i can of Binder
A brief description of the sample: 1 can PG 64-16 binder
From where was the sample collected: Source
Laboratory sample identification: 24-043
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:
