Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995152 DEA: 081J6404
QA Service Level: 1
DIST-CO-RTE-PM: 08---
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2024-05-03-34
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Verification
Type of Material: Asphalt Binder
Sample Taken Date: 05/03/2024
Date that the sample was received by the laboratory/organization performing the testing: 05/07/2024
The quantity of what the sample constitutes: 1can
A brief description of the sample: JMF verification sample
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Blue Diamond-Victorville
Performance Grade: PG 64-10
Modified:
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:
