Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000221 DEA: 010M6804 EFIS: 0123000055
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-36-6.0/13.4
Work Description: MICRO-SURFACING, LOW CARBON MICRO-SURFACING, AND DELINEATION.
Location Description: HUMBOLDT COUNTY NEAR CARLOTTA FROM 0.2 MILE WEST OF WILDER ROAD TO VAN DUZEN RIVER BRIDGE 04-0094
Contractor Name: PAVEMENT COATINGS CO.
Contractor Address: Unknown
Resident Engineer: Cody Long Structure Rep.: Unknown
DIME Sample ID: 2024-08-12-74
TL Number from the TL Form: 876488
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Acceptance
Type of Material: Asphaltic Emulsion
Sample Taken Date: 08/12/2024
Date that the sample was received by the laboratory/organization performing the testing: 08/23/2024
The quantity of what the sample constitutes: 1 OF 1
A brief description of the sample: MIRCO
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Western Emulsions Inc
