Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212498 DEA: 021H5204 EFIS: 0217000009
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS-3,263-48.5/49.7 - 49.41
Work Description: Roadway Rehabilitation
Location Description: 02-Sis-3, 263-R46.8/R48.0, 49.07/49.41
Contractor Name: Myers-Shea JV
Contractor Address: 45 Morrison Ave, Sacramento, CA 95838
Resident Engineer: Austin Henry Structure Rep.: Nicolas Jimenez
DIME Sample ID: 2022-09-02-68
TL Number from the TL Form: 891190
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 Binder
Sample Taken Date: 09/02/2022
Date that the sample was received by the laboratory/organization performing the testing: 09/21/2022
The quantity of what the sample constitutes: 2 cans
A brief description of the sample: 58-34m, 23.6% Rap
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: JF Shea Fawndale
Performance Grade: PG 58-34 M
Modified: Yes
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Valero Marketing & Supply - Benicia CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
