Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214731 DEA: 051M0004 EFIS: 0519000047
QA Service Level: 1
DIST-CO-RTE-PM: 05-SLO-101-16.5/R21.5
Work Description: COLD PLANE AND RHMA-GAP GRADED OVERLAY ON EXISTING ROADWAY.
Location Description: SAN LUIS OBISPO COUNTY IN AND NEAR PISMO BEACH FROM 0.1 MILE SOUTH OF PRICE CANYON ROAD TO SAN LUIS CREEK BRIDGE
Contractor Name: PAPICH CONSTRUCTION COMPANY, INC.
Contractor Address: 398 SUNRISE TERRACE, ARROYO GRANDE, CA 93425
Resident Engineer: Lilian Bennetzen Structure Rep.: Unknown
DIME Sample ID: 2020-06-12-20
TL Number from the TL Form:
Sample Submitted By Organization: CT D05 - San Luis Obispo District Laboratory
Sample Organization Contact: (559) 230-3109
Type of Sample: Verification
Type of Material: Asphalt Binder
Sample Taken Date: 06/12/2020
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: One JMF Verification
A brief description of the sample: Quart can of Binder
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: San Joaquin
Performance Grade: PG 64-10
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier:
Multigrade:
Multigrade Type:
Asphalt Binder Mix Number:
