Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214964 DEA: 051F9204 EFIS: 0514000075
QA Service Level: 1
DIST-CO-RTE-PM: 05-SCR-9-0.9/7.5
Work Description: REMOVE AND REPLACE DRAINAGE SYSTEMS.
Location Description: SANTA CRUZ COUNTY IN AND NEAR SANTA CRUZ AT VARIOUS LOCATIONS FROM 0.4 MILE NORTH OF VERNON STREET TO EL SOLYO HEIGHTS DRIVE
Contractor Name: Disney Construction
Contractor Address: 533 airport Blvd, Suite 120, Burlingame, CA 94010
Resident Engineer: Ian Nguyen Structure Rep.: Unknown
DIME Sample ID: 2021-09-23-54
TL Number from the TL Form:
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: 09/23/2021
Date that the sample was received by the laboratory/organization performing the testing: 10/01/2021
The quantity of what the sample constitutes: 1 can
A brief description of the sample: 64-10
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Granite Felton
Performance Grade: PG 64-10
Modified: No
Lot number: 1
Sublot number: 1
Tank number:
Time of sample:
HMA Supplier: Granite Felton
Certified Asphalt Supplier: Valero Marketing & Supply - Benicia CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
