Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214175 DEA: 030H4804 EFIS: 0315000198
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-99-0.1/1.6,11.8/21.6
Work Description: COLD PLANE AC PAVEMENT AND RHMA OVERLAY.
Location Description: SACRAMENTO COUNTY IN AND NEAR GALT FROM DRY CREEK BRIDGE TO SIMMERHORN ROAD AND IN ELK GROVE AND SACRAMENTO FROM 0.9 MILE SOUTH OF ELK GROVE BOULEVARD TO MARTIN LUTHER KING JR BOULEVARD
Contractor Name: MERCER-FRASER COMPANY
Contractor Address: PO Box 1006, Eureka, CA 95502
Resident Engineer: Sushma Lee Structure Rep.: Kim Noonan
DIME Sample ID: 2021-06-10-17
TL Number from the TL Form: c724398
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Acceptance
Type of Material: Asphalt Rubber Binder
Sample Taken Date: 06/10/2021
Date that the sample was received by the laboratory/organization performing the testing: 06/14/2021
The quantity of what the sample constitutes: 1 can
A brief description of the sample: Rubberized PG64-16
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: George Reed - Clements Plant
Asphalt modifier supplier:
Performance Grade: PG 64-16
Lot number:
Sublot number:
Asphalt Rubber Binder Mix Number: