Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215073 DEA: 034H5604 EFIS: 0318000332
QA Service Level: 1
DIST-CO-RTE-PM: 03-PLA-65-R12.9/R13.1
Work Description: CONSTRUCT SLOPE PAVING AND PLACE EROSION CONTROL.
Location Description: PLACER COUNTY IN LINCOLN AT THE SOUTH INGRAM SLOUGH BRIDGE
Contractor Name: McCuen Construction, Inc.
Contractor Address: 3269 Swetzer Road, Loomis, CA,95690
Resident Engineer: Berhane Tesfagabar Structure Rep.: Unknown
DIME Sample ID: 2021-03-02-33
TL Number from the TL Form: c764977
Sample Submitted By Organization: CT D03 - Olivehurst Northern Regional Laboratory
Sample Organization Contact: (530) 741-4238
Type of Sample: Verification
Type of Material: Asphalt Binder
Sample Taken Date: 03/02/2021
Date that the sample was received by the laboratory/organization performing the testing: 03/02/2021
The quantity of what the sample constitutes: JMF Verification
A brief description of the sample: PG 64-16 (mix 3/4" HMA - A w/12% RAP)
From where was the sample collected: Manufacturer
Laboratory sample identification: JMF21-008
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Vulcan Materials Company - Roseville
Performance Grade: PG 64-16
Modified: No
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Marathon Petroleum Co. LP - Elk Grove CA
Multigrade:
Multigrade Type:
Asphalt Binder Mix Number:
