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: 2021-03-05-14
TL Number from the TL Form:
Sample Submitted By Organization: Veleroo Marketing and Supply
Sample Organization Contact: 222-222-2222
Type of Sample: Dispute Resolution
Type of Material: Asphalt Binder
Sample Taken Date: 03/05/2021
Date that the sample was received by the laboratory/organization performing the testing: 03/01/2021
The quantity of what the sample constitutes: 99
A brief description of the sample: 99
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: 999
Performance Grade: PG 64-16
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Valero Coolidge - Coolidge AZ
Multigrade:
Multigrade Type:
Asphalt Binder Mix Number:
