Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215656 DEA: 032G0604 EFIS: 0320000192
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-5736-
Work Description: REMOVE AND REPLACE CL2 AGGREGATE BASE AND HMA (TYPE A).
Location Description: SACRAMENTO COUNTY IN SACRAMENTO AT THE NORTHGATE MAINTENANCE STATION AT 3940 ROSIN COURT
Contractor Name: FBD VANGUARD CONSTRUCTION, INC.
Contractor Address: 550 Greenville Rd, Livermore, CA 94550
Resident Engineer: Deya Dean Elghassein Structure Rep.: Unknown
DIME Sample ID: 2021-07-08-58
TL Number from the TL Form:
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: 07/08/2021
Date that the sample was received by the laboratory/organization performing the testing: 07/08/2021
The quantity of what the sample constitutes: 2 Cans
A brief description of the sample: PG 64-16, Marathon/Western
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: MarathonWestern
Performance Grade: PG 64-16
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Marathon Petroleum Co. LP - Elk Grove CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
