Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214732 DEA: 051M5004 EFIS: 0519000166
QA Service Level: 1
DIST-CO-RTE-PM: 05-SB-166-0.2/6.9
Work Description: COLD PLANE EXISTING ROADWAY AND PLACE RHMA-G.
Location Description: SANTA BARBARA COUNTY IN AND NEAR GUADALUPE AND SANTA MARIA FROM OBISPO STREET TO BLOSSER ROAD
Contractor Name: CAL PORTLAND CONSTRUCTION
Contractor Address: 1625 E Donovan Road, Santa Maria, CA 93454
Resident Engineer: Thomas Peterson Structure Rep.: Unknown
DIME Sample ID: 2020-07-15-9
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 Rubber Binder
Sample Taken Date: 07/15/2020
Date that the sample was received by the laboratory/organization performing the testing: 07/14/2020
The quantity of what the sample constitutes: One JMF Renewal
A brief description of the sample: Quart can of ARB
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: World Oil
Asphalt modifier supplier:
Performance Grade: PG 64-16
Lot number: 1
Sublot number: 20
Asphalt Rubber Binder Mix Number:
