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: 2024-09-09-123
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: 09/09/2024
Date that the sample was received by the laboratory/organization performing the testing: 10/15/2024
The quantity of what the sample constitutes: 1 CAN OF 64-16
A brief description of the sample: Tank 101
From where was the sample collected: Manufacturer
Laboratory sample identification: 240909-6416-01
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Mojave, CA
Performance Grade: PG 64-16
Modified: No
Lot number:
Sublot number:
Tank number: 101
Time of sample: 9:00 AM
HMA Supplier:
Certified Asphalt Supplier: Western Emulsions Incorporated - Mojave CA
Multigrade: Yes
Multigrade Type: PG 64-16 / PG 64-10
Asphalt Binder Mix Number:
