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: 2019-04-16-30
TL Number from the TL Form: 857584
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: 04/16/2019
Date that the sample was received by the laboratory/organization performing the testing: 04/16/2019
The quantity of what the sample constitutes: JMF Verification
A brief description of the sample: Neat Binder
From where was the sample collected: Manufacturer
Laboratory sample identification: BoL 4080
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Valero-Benicia Asphalt Plant
Performance Grade: PG 64-10
Modified: No
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier:
Multigrade:
Multigrade Type:
Asphalt Binder Mix Number:
DIME Test ID: 2019-04-16-30-1
Test Method: AASHTO T228-09r13: Standard Method of Test for Specific Gravity of Semi-Solid Asphalt Materials (Specific Gravity)
Verified Date: 05/01/2019
Date Tested: 04/16/2019
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: