Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 9999 DEA: 00000000 EFIS: 0000000000 COOP: 99999333399 MINOR: 333333 Permit Numbers: 555555 0400NRT0000
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC,OMG-888,99,80-0.6-0.6
Work Description: THIS PROJECT RECORD WAS ADDED FOR DIME DEVELOPERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT RECORD WAS ADDED FOR DIME DEVELOPERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: YYZ
Contractor Address: 1234 address, Sacramento, CA 95824
Resident Engineer: RE_first RE_last Structure Rep.: SR_First SR_Last
DIME Sample ID: 2022-07-12-2
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Materials Management Branch Field Office
Sample Organization Contact: (562) 500-5861
Type of Sample: Quality Assurance
Type of Material: Asphalt Binder
Sample Taken Date: 07/12/2022
Date that the sample was received by the laboratory/organization performing the testing: 07/13/2022
The quantity of what the sample constitutes: 1 ton
A brief description of the sample: TEST Asphalt Rubber Binder
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Testing for APP
Performance Grade: PG 58-16
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Oregon Corp - Salem OR
Multigrade: Yes
Multigrade Type:
Asphalt Binder Mix Number:
