Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215441 DEA: 021J5204 EFIS: 0220000087
QA Service Level: 1
DIST-CO-RTE-PM: 02-MOD,SIS-139-34.0/50.7,0.0/5.0
Work Description: PLACE ASPHALT RUBBER BINDER CHIP SEAL & REPLACE AC SURFACING.
Location Description: MODOC AND SISKIYOU COUNTIES AT AND NEAR NEWELL FROM 3.3 MILES NORTH OF PEREZ OVERHEAD TO ROUTE 161
Contractor Name: AMERICAN PAVEMENT SYSTEMS, INC.
Contractor Address: 1012 11th St., Modesto, CA 95354
Resident Engineer: Austin Henry Structure Rep.: Unknown
DIME Sample ID: 2021-06-16-24
TL Number from the TL Form: c815581
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: 06/16/2021
Date that the sample was received by the laboratory/organization performing the testing: 07/02/2021
The quantity of what the sample constitutes: 1 of 1 gallon can
A brief description of the sample: Rubberized PG58-22
From where was the sample collected: Distributor
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Albina - Klamath Falls
Asphalt modifier supplier:
Performance Grade: PG 58-22
Lot number:
Sublot number:
Asphalt Rubber Binder Mix Number:
