Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212910 DEA: 080K2914 EFIS: 0812000098
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-10-30.9/33.3
Work Description: LANE REPLACEMENT
Location Description: SAN BERNARDINO COUNTY IN REDLANDS FROM ORANGE STREET UNDERCROSSING TO REDLANDS BLVD OFF-RAMP UNDERCROSSING
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 13170 TELFAIR AVENUE, SYLMAR, CA 91342
Resident Engineer: Nick Truong Structure Rep.: Ali El-Zaynab
DIME Sample ID: 2019-02-20-8
TL Number from the TL Form:
Sample Submitted By Organization: CT D08 - Fontana Southern Regional Laboratory
Sample Organization Contact: 213-792-4794
Type of Sample: Department Acceptance
Type of Material: Asphalt Binder
Sample Taken Date: 02/20/2019
Date that the sample was received by the laboratory/organization performing the testing: 02/21/2019
The quantity of what the sample constitutes: 1 qt can
A brief description of the sample: PG64-28M
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: SJR
Performance Grade: PG64-28M
Modified: Yes
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier:
Multigrade:
Multigrade Type:
Asphalt Binder Mix Number:
