Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 99999 DEA: 0322222
QA Service Level:
DIST-CO-RTE-PM: 03-SAC,OMG-888,99,80-0.6-0.6
Work Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Michael Maksimovich Structure Rep.: Unknown
DIME Sample ID: 2020-12-14-6
TL Number from the TL Form:
Sample Submitted By Organization: Veleroo Marketing and Supply
Sample Organization Contact: 222-222-2222
Type of Sample: Quality Control
Type of Material: Asphalt Binder
Sample Taken Date: 12/14/2020
Date that the sample was received by the laboratory/organization performing the testing: 12/14/2020
The quantity of what the sample constitutes: 4 cans
A brief description of the sample: Asphalt Binder Sample COC
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 64-16
Modified: No
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier:
Multigrade:
Multigrade Type:
Asphalt Binder Mix Number:
