Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 9999 DEA: 00000000 EFIS: 0000000000 COOP: 99999333399 MINOR: 333333 Permit Numbers: 555555 0400NRT0000
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC,OMG-888,99,80-0.6-0.6
Work Description: THIS PROJECT RECORD WAS ADDED FOR DIME DEVELOPERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT RECORD WAS ADDED FOR DIME DEVELOPERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: YYZ
Contractor Address: 1234 address, Sacramento, CA 95824
Resident Engineer: RE_first RE_last Structure Rep.: SR_First SR_Last
DIME Sample ID: 2019-02-01-7
TL Number from the TL Form:
Sample Submitted By Organization: Thinh Org
Sample Organization Contact: (111) 998-9858
Type of Sample: Quality Control
Type of Material: Asphalt Binder
Sample Taken Date: 02/01/2019
Date that the sample was received by the laboratory/organization performing the testing: 02/13/2019
The quantity of what the sample constitutes: 1
A brief description of the sample: testing
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: aaa
DIME Test ID: 2019-02-01-7-1
Test Method: AASHTO T228-09r13: Standard Method of Test for Specific Gravity of Semi-Solid Asphalt Materials (Specific Gravity)
Verified Date: 02/13/2019
Date Tested: 02/01/2019
Submitted By Organization: Thinh Org
Organization Address: 1111 S Street,
Organization City: Folsom
Organization State: CA
Organization Zipcode: 99999
Organization Email: ttt@ttt.com
Organization Phone: (111) 998-9858
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
