Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214321 DEA: 012982U4 EFIS: 0118000125
QA Service Level: 1
DIST-CO-RTE-PM: 01-LAK-29,175-28.5/31.6,8.2/8.5
Work Description: CONSTRUCT 4 LANE EXPRESSWAY WITH EARTHWORK AND PAVING.
Location Description: LAKE COUNTY NEAR KELSEYVILLE ON ROUTE 29 FROM 0.6 MILE TO 3.7 MILES NORTH OF ROUTE 281 AND ON ROUTE 175 FROM SOUTH JUNCTION ROUTE 29 TO 0.3 MILE EAST OF SOUTH JUNCTION ROUTE 29
Contractor Name: FBD VANGUARD CONSTRUCTION, INC.
Contractor Address: 550 Greenville Rd, Livermore, CA 94550
Resident Engineer: Dan Kraft Structure Rep.: Tatjana Halda
DIME Sample ID: 2022-04-06-28
TL Number from the TL Form: 035682
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Department Acceptance
Type of Material: Asphalt Rubber Binder
Sample Taken Date: 04/06/2022
Date that the sample was received by the laboratory/organization performing the testing: 04/18/2022
The quantity of what the sample constitutes: 1 can, no test
A brief description of the sample: Asphalt Rubber Binder
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Unknown
Asphalt modifier supplier:
Performance Grade: PG 64-16
Lot number:
Sublot number:
Asphalt Rubber Binder Mix Number:
