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: 2021-03-03-4
TL Number from the TL Form:
Sample Submitted By Organization: Veleroo - Coolidge
Sample Organization Contact: 111-111-1111
Type of Sample: Quality Control
Type of Material: Asphalt Binder
Sample Taken Date: 03/03/2021
Date that the sample was received by the laboratory/organization performing the testing: 03/04/2021
The quantity of what the sample constitutes: 90 CY
A brief description of the sample: HMA Type A
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Wowxx
Performance Grade: PG 64-10
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier: Chowchilla Asphalt Incorporated - Chowchilla CA
Certified Asphalt Supplier: Marathon Petroleum Co. LP - Mojave CA
Multigrade:
Multigrade Type:
Asphalt Binder Mix Number:
