Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 44444 DEA: ASCP EFIS: ASCP
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for submitting Sample information for Asphalt Supplier Certification Program.
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2024-06-19-116
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: Asphalt Binder
Sample Taken Date: 06/19/2024
Date that the sample was received by the laboratory/organization performing the testing: 07/01/2024
The quantity of what the sample constitutes: 1 Can
A brief description of the sample: Asphalt Binder "Non-M" PG58-34
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: albina
Performance Grade: PG 58-34 M
Modified: No
Lot number:
Sublot number:
Tank number: Tank 34
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Albina Asphalt (Klamath Falls Plant) - Klamath Falls OR
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
