Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995514 DEA: 024J8204 EFIS: 0223000077
QA Service Level: 1
DIST-CO-RTE-PM: 02-MOD-299-14.7/20.0
Work Description: SCHAFFER MT CHIP - PLACE ASPHALT RUBBER CHIP SEAL WITH REPLACE AC SURFACING.
Location Description: MODOC COUNTY NEAR CANBY FROM 0.1 MILE EAST OF COUNTY ROAD 85 TO 1.7 MILES WEST OF ROUTE 139
Contractor Name: AMERICAN PAVEMENT SYSTEMS, INC.
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2024-08-14-79
TL Number from the TL Form: C858018
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: 08/14/2024
Date that the sample was received by the laboratory/organization performing the testing: 08/28/2024
The quantity of what the sample constitutes: 1 jar
A brief description of the sample: CSS-1H FOG SEAL
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Albina - Klamath Falls, OR
