Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214190 DEA: 024G41U4 EFIS: 0218000047
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS,SIS-5-Var
Work Description: REPLACE REINFORCED CONCRETE BRIDGES & CONSTRUCT RETAINING WALL.
Location Description: SHASTA AND SISKIYOU COUNTIES ABOUT 7 MILES NORTH OF POLLARD FLAT FROM 0.8 MILE SOUTH TO 0.7 MILE NORTH OF SIMS ROAD UNDERCROSSING AND FROM 0.6 MILE SOUTH OF CASTLE CRAGS DRIVE UNDERCROSSING TO 0.2 MILE SOUTH OF SOUTH DUNSMUIR UNDERCROSSING
Contractor Name: J.F. Shea Construction, Inc.
Contractor Address: 17400 Clear Creek Road, Redding, CA 96001
Resident Engineer: Nicole Mallory Structure Rep.: Adam Scardaci
DIME Sample ID: 2020-10-08-36
TL Number from the TL Form: 779353
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Acceptance
Type of Material: Asphalt Binder
Sample Taken Date: 10/08/2020
Date that the sample was received by the laboratory/organization performing the testing: 10/15/2020
The quantity of what the sample constitutes: 1 Can
A brief description of the sample: PG 58-34M #2 No test
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Valero Benicia
Performance Grade: PG 58-34 M
Modified: Yes
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Valero Marketing & Supply - Benicia CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
