Sample Record for 2020-04-08-21

Project ID: 214190 DEA: 024G41U4 EFIS: 0218000047 QA Service Level: 1

DIST-CO-RTE-PM: 02-SIS,SIS-5-Var

Work Description: REPLACE REINFORCED CONCRETE BRIDGES & CONSTRUCT RETAINING WALL.

Location Description: SHASTA AND SISKIYOU COUNTIES ABOUT 7 MILES NORTH OF POLLARD FLAT FROM 0.8 MILE SOUTH TO 0.7 MILE NORTH OF SIMS ROAD UNDERCROSSING AND FROM 0.6 MILE SOUTH OF CASTLE CRAGS DRIVE UNDERCROSSING TO 0.2 MILE SOUTH OF SOUTH DUNSMUIR UNDERCROSSING

Contractor Name: J.F. Shea Construction, Inc.

Contractor Address: 17400 Clear Creek Road, Redding, CA 96001

Resident Engineer: Nicole Mallory Structure Rep.: Adam Scardaci

DIME Sample ID: 2020-04-08-21

TL Number from the TL Form: 897565

Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory

Sample Organization Contact: (916) 227-7302

Type of Sample: Acceptance

Type of Material: Asphalt Binder

Sample Taken Date: 04/08/2020

Date that the sample was received by the laboratory/organization performing the testing: 05/28/2020

The quantity of what the sample constitutes: 1 Can

A brief description of the sample: Modified Asphalt Binder

From where was the sample collected: Distributor

Laboratory sample identification: AB206018

Structure unique identifier:

Structure name:

The fabricator/manufacturer/facility name: Valero

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: