Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213134 DEA: 024F77U4 EFIS: 0217000022
QA Service Level: 1
DIST-CO-RTE-PM: 02-MOD-299-23.1/23.6, 24.5/33.5
Work Description: BRIDGE REPLACE, ROADWAY REHAB/FULL DEPTH RECLAMATION-CEMENT + HMA
Location Description: MODOC COUNTY ABOUT 6 MILES WEST OF ALTURAS FROM 0.3 MILE WEST TO 0.3 MILE EAST OF CALDWELL CREEK BRIDGE AND 1.1 MILES EAST OF CALDWELL CREEK BRIDGE TO 1.7 MILES WEST OF COUNTY ROAD 75
Contractor Name: Hat Creek Construction & Materials, Incorporated
Contractor Address: 24339 Highway 89 N, Burney, CA 96013
Resident Engineer: Mike Zdenek Structure Rep.: Ryan Duran
DIME Sample ID: 2018-09-11-14
TL Number from the TL Form: 002271
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: 09/11/2018
Date that the sample was received by the laboratory/organization performing the testing: 09/12/2018
The quantity of what the sample constitutes: JMF Verification
A brief description of the sample: Modified Binder with 0.1% ZycoTherm
From where was the sample collected: Manufacturer
Laboratory sample identification: D77631
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Albina - 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: 2018-09-11-14-1
Test Method: AASHTO T228-09r13: Standard Method of Test for Specific Gravity of Semi-Solid Asphalt Materials (Specific Gravity)
Verified Date: 09/20/2018
Date Tested: 08/27/2018
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:
