Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214515 DEA: 024F6004 EFIS: 0213000012
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS,TRI-36,96,299-VAR
Work Description: BRIDGE DECK REPAIR, POLYESTER OVERLAY AND RAIL REPLACEMENT.
Location Description: SISKIYOU AND TRINITY COUNTIES AT VARIOUS LOCATIONS
Contractor Name: MYERS AND SONS CONSTRUCTION
Contractor Address: 4600 NORTHGATE BLVD, STE #100, SACRAMENTO, CA 95834
Resident Engineer: Sunil Repaka Structure Rep.: Robert Thompson
DIME Sample ID: 2021-07-08-48
TL Number from the TL Form: c853174
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Acceptance
Type of Material: Asphalt Binder
Sample Taken Date: 07/08/2021
Date that the sample was received by the laboratory/organization performing the testing: 08/03/2021
The quantity of what the sample constitutes: 2 of 2 cans
A brief description of the sample: NO TEST
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Valero - Benicia
Performance Grade: PG 64-28 M
Modified: Yes
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier: Mercer Fraser - Willowcreek
Certified Asphalt Supplier: Valero Marketing & Supply - Benicia CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
