Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 99999 DEA: 0322222
QA Service Level:
DIST-CO-RTE-PM: 03-SAC,OMG-888,99,80-0.6-0.6
Work Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Michael Maksimovich Structure Rep.: Unknown
DIME Sample ID: 2017-06-16-5
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Los Angeles Field Office
Sample Organization Contact: (858) 285-5797
Type of Sample: Verification
Type of Material: Job Mix Formula Partial
Sample Taken Date: 06/16/2017
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 1000
A brief description of the sample: Asphalt
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan
Source Identification (SMARA, name of Pit or Job Site): Asphalt
The fabricator's/manufacturer's product name for the sample:
The fabricator/manufacturer designation for the sample:
The plant number:
A detailed description of where the material sample was collected: Windrow
Where the material sample would have been placed if not sampled:
Superpave or Non-superpave Mix: Superpave
