Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 210673 DEA: 042640F4 EFIS: 0400020132 COOP: 042308A3
QA Service Level: 1
DIST-CO-RTE-PM: 04-SON--
Work Description:
Location Description:
Contractor Name: GHILOTTI CONSTRUCTION CO. INC.
Contractor Address: 246 GHILOTTI AVENUE, SANTA ROSA, CA 95407
Resident Engineer: Gina Choi Structure Rep.: Brian Beaudoin
DIME Sample ID: 2020-08-18-31
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Hayward DME / District Laboratory
Sample Organization Contact: (510) 507-3456
Type of Sample: Quality Control
Type of Material: Asphalt Binder
Sample Taken Date: 08/18/2020
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 2 cans
A brief description of the sample: Oil-1/2" HMA w/RAP
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Valero Benicia
Performance Grade: PG 64-16
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier:
Multigrade:
Multigrade Type:
Asphalt Binder Mix Number:
