Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 44444 DEA: ASCP EFIS: ASCP
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for submitting Sample information for Asphalt Supplier Certification Program.
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2022-08-17-90
TL Number from the TL Form:
Sample Submitted By Organization: Western Emulsions, Incorporated - White City Emulsion
Sample Organization Contact: (208) 589-8608
Type of Sample: Quality Control
Type of Material: Asphalt Binder
Sample Taken Date: 08/17/2022
Date that the sample was received by the laboratory/organization performing the testing: 09/20/2022
The quantity of what the sample constitutes: 2 qt cans
A brief description of the sample: Asphalt Binder Sample
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Western Emulsion White City
Performance Grade: PG 64-16
Modified: No
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Western Emulsion - White City Emulsion Plant - White City OR
Multigrade: Yes
Multigrade Type: PG 64-16 / PG 64-10
Asphalt Binder Mix Number:
