Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
DEA: No Project
QA Service Level:
DIST-CO-RTE-PM: ---
Work Description: Special project identifier for material not associated with a project
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2022-05-19-76
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: Verification
Type of Material: Asphalt Binder
Sample Taken Date: 05/19/2022
Date that the sample was received by the laboratory/organization performing the testing: 10/05/2022
The quantity of what the sample constitutes: Test
A brief description of the sample: Test
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Test
Performance Grade: PG 58-16
Modified: Yes
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: AASHTO Resource - Frederick MD
Multigrade: Yes
Multigrade Type: PG 58-22 / PG 58-16
Asphalt Binder Mix Number:
