Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 211775 DEA: 024E6504 EFIS: 0212000012
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS-96-R52.5/88.4
Work Description: WIDEN BRIDGES,POLYESTER CONC OVERLAY,COLD PLANE AC PVMT,HMA,GUARDRAIL
Location Description: SISKIYOU COUNTY NEAR SEIAD VALLEY AT VARIOUS LOCATIONS FROM 0.1 MILE WEST OF THOMPSON CREEK BRIDGE TO 0.2 MILE EAST OF BEAVER CREEK BRIDGE
Contractor Name: J.F. Shea Construction, Inc
Contractor Address: 17400 Clearcreek Road, Redding, CA 96001
Resident Engineer: Mark Loader Structure Rep.: Robert Thompson
DIME Sample ID: 2019-05-23-19
TL Number from the TL Form: 001377
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: 05/23/2019
Date that the sample was received by the laboratory/organization performing the testing: 05/23/2019
The quantity of what the sample constitutes: JMF Modification
A brief description of the sample: PG 58-34 M (Valero - Benicia)
From where was the sample collected: Manufacturer
Laboratory sample identification: D77889
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Fawndale Rock and Asphalt
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: 2019-05-23-19-1
Test Method: AASHTO T228-09r13: Standard Method of Test for Specific Gravity of Semi-Solid Asphalt Materials (Specific Gravity)
Verified Date: 06/28/2019
Date Tested: 05/23/2019
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:
