Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212657 DEA: 024G5004 EFIS: 0214000031
QA Service Level: 1
DIST-CO-RTE-PM: 02-TRI-299-1.9-2.3
Work Description: VIADUCT WIDENING
Location Description: TRINITY COUNTY NEAR SALYER FROM 0.1 MILE EAST TO 0.6 MILE EAST OF WHITE HOUSE GULCH ROAD
Contractor Name: MERCER-FRASER COMPANY
Contractor Address: PO Box 1006, Eureka, CA 95502
Resident Engineer: Mandhir Grewal Structure Rep.: Michael Mccracken
DIME Sample ID: 2020-10-13-16
TL Number from the TL Form: 037260
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Quality Assurance
Type of Material: Asphalt Binder
Sample Taken Date: 10/13/2020
Date that the sample was received by the laboratory/organization performing the testing: 10/23/2020
The quantity of what the sample constitutes: 1 can
A brief description of the sample: AB PG 64-28M No Test #2, #3(885337)
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 64-28 M
Modified: Yes
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier:
Multigrade:
Multigrade Type:
Asphalt Binder Mix Number:
