Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994671 DEA: 010H8004 EFIS: 0118000110
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-254-4.3/4.7
Work Description: Project Name: Myers Flat Permanent Restoration
Location Description: Bridge No. 04E0041
Contractor Name: McCullough Construction Inc.
Contractor Address: 57 Alder Grove Road, Arcata, CA 95521
Resident Engineer: Cody Long Structure Rep.: George Moore
DIME Sample ID: 2024-06-27-24
TL Number from the TL Form: 972275
Sample Submitted By Organization: CT D01 - District 1 Materials Laboratory
Sample Organization Contact: (707) 496-0974
Type of Sample: Acceptance
Type of Material: Asphalt Binder
Sample Taken Date: 06/27/2024
Date that the sample was received by the laboratory/organization performing the testing: 06/27/2024
The quantity of what the sample constitutes: 1 can of binder
A brief description of the sample: 1 can of PG 64-16 binder
From where was the sample collected: Source
Laboratory sample identification: 24-101
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Kernen Blue Lake Plant
Performance Grade: PG 64-16
Modified: No
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: VSS Emutech - Redding CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
