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: 2022-11-16-39
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Verification
Type of Material: Asphalt Binder
Sample Taken Date: 11/16/2022
Date that the sample was received by the laboratory/organization performing the testing: 12/16/2022
The quantity of what the sample constitutes: 1 quart can
A brief description of the sample: Tank 2001
From where was the sample collected: Manufacturer
Laboratory sample identification: AC-2189-WS
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: West Sacramento,CA
Performance Grade: PG 64-16
Modified: No
Lot number:
Sublot number:
Tank number: 2001
Time of sample: 8am
HMA Supplier:
Certified Asphalt Supplier: VSS Emultech - West Sacramento CA
Multigrade: Yes
Multigrade Type: PG 64-16 / PG 64-10
Asphalt Binder Mix Number:
