Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214591 DEA: 051M2704 EFIS: 0519000089
QA Service Level: 1
DIST-CO-RTE-PM: 05-SB-150-0.0/2.2
Work Description: RHMA OVERLAY, FULL WIDTH SEGMENT CORRECTION AND COLD PLANE AC.
Location Description: SANTA BARBARA COUNTY IN AND NEAR CARPINTERIA FROM ROUTE 101/150 SEPARATION TO VENTURA COUNTY LINE
Contractor Name: TORO ENTERPRISES INC
Contractor Address: P O BOX 6285, OXNARD CA 93030
Resident Engineer: Michael Mortensen Structure Rep.: Unknown
DIME Sample ID: 2020-09-21-30
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: 09/21/2020
Date that the sample was received by the laboratory/organization performing the testing: 09/22/2020
The quantity of what the sample constitutes: One JMF Verification
A brief description of the sample: Quart of ARB
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan
Asphalt modifier supplier:
Performance Grade: PG 64-16
Lot number:
Sublot number:
Asphalt Rubber Binder Mix Number:
