Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212680 DEA: 024F5504 EFIS: 0213000005
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS-89-20.9 - 21.2
Work Description: BRIDGE REPLACEMENT WITH PRE-CAST I-GIRDER AND RECONSTRUCT HIGHWAY
Location Description: SISKIYOU COUNTY NEAR MCCLOUD FROM 0.2 MILE SOUTH TO 0.2 MILE NORTH OF MUD CREEK BRIDGE
Contractor Name: STEELHEAD CONSTRUCTORS, INC.
Contractor Address: PO Box 997, Palo Cedro, CA 96073
Resident Engineer: Mike Zdenek Structure Rep.: Ryan Duran
DIME Sample ID: 2017-04-24-7
TL Number from the TL Form: 853535
Sample Submitted By Organization: CT D02 - Redding Northern Regional Laboratory
Sample Organization Contact: (530) 225-3194
Type of Sample: Verification
Type of Material: Asphalt Binder
Sample Taken Date: 04/24/2017
Date that the sample was received by the laboratory/organization performing the testing: 04/24/2017
The quantity of what the sample constitutes: JMF
A brief description of the sample: Contractor Data for JMF
From where was the sample collected: Manufacturer
Laboratory sample identification: D77366
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Valero-Benicia Asphalt Plant
Performance Grade: PG 64-28 PM
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier:
Multigrade:
Multigrade Type:
Asphalt Binder Mix Number:
DIME Test ID: 2017-04-24-7-1
Test Method: AASHTO T228-09r13: Standard Method of Test for Specific Gravity of Semi-Solid Asphalt Materials (Specific Gravity)
Verified Date: 07/10/2018
Date Tested: 04/20/2017
Submitted By Organization: CT D02 - Redding Northern Regional Laboratory
Organization Address: 1657 Riverside Drive,
Organization City: Redding
Organization State: CA
Organization Zipcode: 96001
Organization Email: ward.jenkins@dot.ca.gov
Organization Phone: 530-225-3194
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
