Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214658 DEA: 051K7104 EFIS: 0518000232
QA Service Level: 1
DIST-CO-RTE-PM: 05-SLO-46,101-var
Work Description: PLACE METHACRYLATE DECK SEAL, POLYESTER CONCRETE OVERLAY, JOINT SEALS
Location Description: SAN LUIS OBISPO COUNTY IN AND NEAR PASO ROBLES AT VARIOUS LOCATIONS
Contractor Name: AMERICAN CIVIL CONSTRUCTORS WEST COAST LLC
Contractor Address: 2990 Bay Vista Court Suite D, Benicia, CA 94510
Resident Engineer: Johnny Rodriguez Structure Rep.: Salvador J 'Sal' Heredia,
DIME Sample ID: 2020-08-14-32
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: Warm Mix Asphalt Technology
Sample Taken Date: 08/14/2020
Date that the sample was received by the laboratory/organization performing the testing: 09/09/2020
The quantity of what the sample constitutes: One JMF Verification
A brief description of the sample: Pint of WMA
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Road Science
