Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214629 DEA: 051H9304 EFIS: 0517000017
QA Service Level: 1
DIST-CO-RTE-PM: 05-SLO-46-R17.2/R17.6
Work Description: CONSTRUCT ROUNDABOUT.
Location Description: SAN LUIS OBISPO COUNTY NEAR TEMPLETON FROM 0.2 MILE WEST TO 0.2 MILE EAST OF VINEYARD DRIVE
Contractor Name: CAL PORTLAND CONSTRUCTION
Contractor Address: 1625 E Donovan Road, Santa Maria, CA 93454
Resident Engineer: Rick Silva Structure Rep.: Salvador J Heredia
DIME Sample ID: 2020-09-17-22
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: 09/17/2020
Date that the sample was received by the laboratory/organization performing the testing: 09/25/2020
The quantity of what the sample constitutes: One JMF Verification
A brief description of the sample: Quart Can Binder
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Valero
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:
