Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212562 DEA: 024G5504 EFIS: 0214000036
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS-5-2.7/R11.4
Work Description: RECONSTRUCT WITH HMA AND PCC, WIDEN STRUCTURE AND UPGRADE RAILS
Location Description: SISKIYOU COUNTY IN AND NEAR DUNSMUIR FROM SACRAMENTO RIVER BRIDGE TO 0.6 MILE SOUTH OF NORTH MOUNT SHASTA UNDERPASS
Contractor Name: J.F. SHEA CONSTRUCTION
Contractor Address: P.O. BOX 494519, REDDING, CA 96049-4519
Resident Engineer: Nicole Mallory Structure Rep.: Andrew Osullivan
DIME Sample ID: 2019-06-11-21
TL Number from the TL Form: 991054
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: 06/11/2019
Date that the sample was received by the laboratory/organization performing the testing: 06/12/2019
The quantity of what the sample constitutes: JMF Renewal
A brief description of the sample: PG 58-34 M (Albina – Klamath Falls)
From where was the sample collected: Manufacturer
Laboratory sample identification: D77929
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Albina - Klamath Falls, 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: 2019-06-11-21-1
Test Method: AASHTO T228-09r13: Standard Method of Test for Specific Gravity of Semi-Solid Asphalt Materials (Specific Gravity)
Verified Date: 07/26/2019
Date Tested: 06/12/2019
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:
