Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 44444 DEA: ASCP EFIS: ASCP
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for submitting Sample information for Asphalt Supplier Certification Program.
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2021-02-17-19
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Informational
Type of Material: Asphalt Binder
Sample Taken Date: 02/17/2021
Date that the sample was received by the laboratory/organization performing the testing: 03/29/2021
The quantity of what the sample constitutes: 1 OF 4 CANS
A brief description of the sample: Asphalt Binder Sample
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: World Oil
Performance Grade: PG 58-22
Modified: No
Lot number: 021721037
Sublot number:
Tank number: 1234
Time of sample: 1230AM
HMA Supplier:
Certified Asphalt Supplier: Lunday Thagard Company-World Oil - South Gate CA
Multigrade:
Multigrade Type:
Asphalt Binder Mix Number:
