Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 66667 DEA: JMFPP EFIS: 0019000043
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for submitting Sample information for JMF Prequalification Program.
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2023-05-24-50
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: 05/24/2023
Date that the sample was received by the laboratory/organization performing the testing: 05/24/2023
The quantity of what the sample constitutes: 4 binder cans
A brief description of the sample: binder for JMFPP
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: SJR
Performance Grade: PG 64-10
Modified: No
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier: Jaxon - Deer Creek
Certified Asphalt Supplier: San Joaquin Refinery - Bakersfield CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number: 23101126305pg6410
