Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215660 DEA: 040W3804 EFIS: 0420000211
QA Service Level: 1
DIST-CO-RTE-PM: 04-SM-92-R9.5/R10.4
Work Description: COLD PLANE AC PAVEMENT AND PLACE RHMA (G).
Location Description: SAN MATEO COUNTY IN SAN MATEO FROM 0.1 MILE EAST OF WEST HILLSDALE BOULEVARD UNDERCROSSING TO 0.1 MILE WEST OF ALAMEDA DE LAS PULGAS OVERCROSSING
Contractor Name: GRANITE ROCK COMPANY
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2021-07-13-33
TL Number from the TL Form:
Sample Submitted By Organization: CT D04 - Hayward DME / District Laboratory
Sample Organization Contact: (510) 507-3456
Type of Sample: Verification
Type of Material: Asphalt Binder
Sample Taken Date: 07/13/2021
Date that the sample was received by the laboratory/organization performing the testing: 08/26/2021
The quantity of what the sample constitutes: 2 cans
A brief description of the sample: 2 Cans of Asphalt Binder
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Central Concrete Redwood City Plant
Performance Grade: PG 64-16
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier: Peninsula Road Materials
Certified Asphalt Supplier: Valero Marketing & Supply - Benicia CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
