Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993297 DEA: 010F8204 EFIS: 0116000067
QA Service Level: 1
DIST-CO-RTE-PM: 01-HUM-101-R90.1/109.6
Work Description: PLACE RHMA-G AND HMA (TYPE A).
Location Description: IN HUMBOLDT COUNTY IN AND NEAR TRINIDAD FROM 1.3 MILES SOUTH OF SCHOOL ROAD OVERCROSSING TO 0.4 MILE NORTH OF BIG LAGOON BRIDGE
Contractor Name: MERCER-FRASER COMPANY
Contractor Address: 77 West Second Street, Eureka, CA 95501
Resident Engineer: Ryan Dunne Structure Rep.: Michele Stover
DIME Sample ID: 2022-08-30-52
TL Number from the TL Form: 032407
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Acceptance
Type of Material: Asphalt Rubber Binder
Sample Taken Date: 08/30/2022
Date that the sample was received by the laboratory/organization performing the testing: 09/01/2022
The quantity of what the sample constitutes: 1 Can
A brief description of the sample: Asphalt Rubber Binder PG 64-16
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Mercer Fraser Fortuna Plant B
Asphalt modifier supplier:
Performance Grade: PG 64-16
Lot number:
Sublot number:
Asphalt Rubber Binder Mix Number:
