Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213720 DEA: 024H2004 EFIS: 0218000094
QA Service Level: 1
DIST-CO-RTE-PM: 02-SHA-89-26.3/29.2
Work Description: PAVEMENT OVERLAY
Location Description: SHASTA COUNTY ABOUT 10 MILES NORTH OF BURNEY FROM 0.3 MILE NORTH OF CLARK CREEK ROAD TO LAKE BRITTON BRIDGE
Contractor Name: Hat Creek Construction
Contractor Address: 24339 Highway 89 N, Burney, CA 96013
Resident Engineer: TOFAEL ANWAR Structure Rep.: Unknown
DIME Sample ID: 2019-04-17-29
TL Number from the TL Form: 853332
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: 04/17/2019
Date that the sample was received by the laboratory/organization performing the testing: 04/18/2019
The quantity of what the sample constitutes: JMF Verification
A brief description of the sample: Modified Binder
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Albina - Madras, OR
Performance Grade: PG 58-34 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: 2019-04-17-29-1
Test Method: AASHTO T228-09r13: Standard Method of Test for Specific Gravity of Semi-Solid Asphalt Materials (Specific Gravity)
Verified Date: 05/14/2019
Date Tested: 04/09/2019
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: Value from CEM-3512
Test Result Compliance:
Additional Comments When Verified:
