Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212497 DEA: 024E0204 EFIS: 0200020196
QA Service Level: 1
DIST-CO-RTE-PM: 02-SHA-299-77.8/79.7
Work Description: PULVERIZE AND RECONSTRUCT PAVEMENT, AND WIDEN WITH AB, HMA, & RHMA
Location Description: SHASTA COUNTY NEAR BURNEY FROM 0.2 MILE WEST OF SONOMA STREET TO 0.3 MILE WEST OF ROUTE 89
Contractor Name: HAT CREEK CONSTRUCTION & MATERIALS, INC.
Contractor Address: 24339 Highway 89, N. Burney, CA 96013
Resident Engineer: Tofael Anwar Structure Rep.: Christopher S 'Chris' Brace
DIME Sample ID: 2018-04-12-12
TL Number from the TL Form: 853527
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: 04/12/2018
Date that the sample was received by the laboratory/organization performing the testing: 04/13/2018
The quantity of what the sample constitutes: CoC
A brief description of the sample: PG 64-28 M
From where was the sample collected: Manufacturer
Laboratory sample identification: D77324
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Albina Asphalt - Klamath FAlls, OR
Performance Grade: PG 64-28 M
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: 2018-04-12-12-1
Test Method: AASHTO T228-09r13: Standard Method of Test for Specific Gravity of Semi-Solid Asphalt Materials (Specific Gravity)
Verified Date: 08/20/2018
Date Tested: 03/11/2016
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:
