Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213469 DEA: 024C40V4 EFIS: 0218000125
QA Service Level: 1
DIST-CO-RTE-PM: 02-SHA-5-R3.8/R11.7
Work Description: WIDEN TO 6 LANES, BRIDGE REPLACEMENT AND WIDENING AND ROADWAY REHAB
Location Description: SHASTA COUNTY IN AND NEAR ANDERSON FROM ROUTE 5/273 SEPARATION TO 0.4 MILE SOUTH OF CHURN CREEK ROAD OVERCROSSING
Contractor Name: J.F. SHEA CONSTRUCTION
Contractor Address: P.O. BOX 494519, REDDING, CA 96049-4519
Resident Engineer: Henry Benner Structure Rep.: Eric Chaffee
DIME Sample ID: 2019-03-20-14
TL Number from the TL Form:
Sample Submitted By Organization: CT D02 - Redding Northern Regional Laboratory
Sample Organization Contact: (530) 225-3194
Type of Sample: Quality Control
Type of Material: Asphalt Binder
Sample Taken Date: 03/20/2019
Date that the sample was received by the laboratory/organization performing the testing: 03/20/2019
The quantity of what the sample constitutes: Mix Design
A brief description of the sample: Modified Asphalt Binder
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Valero-Benicia Asphalt Plant
Performance Grade: PG 64-28 M
Modified: Yes
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier:
Multigrade:
Multigrade Type:
Asphalt Binder Mix Number:
DIME Test ID: 2019-03-20-14-1
Test Method: AASHTO T228-09r13: Standard Method of Test for Specific Gravity of Semi-Solid Asphalt Materials (Specific Gravity)
Verified Date: 04/12/2019
Date Tested: 03/20/2019
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:
