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: 2022-08-17-53
TL Number from the TL Form: 036331
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: 08/17/2022
Date that the sample was received by the laboratory/organization performing the testing: 08/24/2022
The quantity of what the sample constitutes: 1 can
A brief description of the sample: 58-34 PMR25
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Granite 175
Performance Grade: PG 58-34 M
Modified: Yes
Lot number:
Sublot number:
Tank number:
Time of sample: 0638
HMA Supplier:
Certified Asphalt Supplier: Valero Marketing & Supply - Benicia CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
