Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213791 DEA: 024H2204 EFIS: 0218000096
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS-89-28.0/34.0
Work Description: PAVEMENT OVERLAY.
Location Description: SISKIYOU COUNTY NEAR MCCLOUD FROM 0.5 MILE SOUTH OF MOUNTAIN HOUSE ROAD TO 0.3 MILE SOUTH OF AZALEA ROAD
Contractor Name: STIMPEL-WIEBELHAUS ASSOC.
Contractor Address: P.O. BOX 492335, REDDING, CA 96049
Resident Engineer: Nicole Mallory Structure Rep.: Unknown
DIME Sample ID: 2019-05-29-30
TL Number from the TL Form: 991044
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: 05/29/2019
Date that the sample was received by the laboratory/organization performing the testing: 05/29/2019
The quantity of what the sample constitutes: JMF Verification
A brief description of the sample: PG 58-34 M (Valero – Benicia)
From where was the sample collected: Manufacturer
Laboratory sample identification: D77896
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Valero - Benicia, CA
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: 2019-05-29-30-1
Test Method: AASHTO T228-09r13: Standard Method of Test for Specific Gravity of Semi-Solid Asphalt Materials (Specific Gravity)
Verified Date: 07/10/2019
Date Tested: 05/29/2019
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:
