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: 2021-03-30-2
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: 03/30/2021
Date that the sample was received by the laboratory/organization performing the testing: 03/30/2021
The quantity of what the sample constitutes: 2 of 2 cans
A brief description of the sample: Asphalt Binder Sample
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: San Joaquin Refinery
Performance Grade: PG 58-16
Modified: No
Lot number:
Sublot number:
Tank number: 1
Time of sample: 7am
HMA Supplier:
Certified Asphalt Supplier: San Joaquin Refinery - Bakersfield CA
Multigrade:
Multigrade Type:
Asphalt Binder Mix Number:
