Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995442 DEA: 024J8604 EFIS: 0223000081
QA Service Level: 1
DIST-CO-RTE-PM: 02-SHA-299-40.7/50.5
Work Description: PLACE ASPHALT-RUBBER CHIP SEAL AND THERMOPLASTIC TRAFFIC STRIPE.
Location Description: SHASTA COUNTY NEAR ROUND MOUNTAIN FROM 0.9 MILE WEST OF SEAMAN GULCH ROAD TO 1.6 MILES EAST OF LIMESTONE QUARRY ROAD
Contractor Name: AMERICAN PAVEMENT SYSTEMS, INC.
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2024-08-13-93
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 Rubber Binder
Sample Taken Date: 08/13/2024
Date that the sample was received by the laboratory/organization performing the testing: 08/21/2024
The quantity of what the sample constitutes: 1 CAN OF RUBBER
A brief description of the sample: 1 CAN OF RUBBER
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Albina - Klamath Falls, OR
Asphalt modifier supplier:
Performance Grade: PG 58-22
Lot number:
Sublot number:
Asphalt Rubber Binder Mix Number:
