Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994845 DEA: 061E6104 EFIS: 0622000068
QA Service Level: 1
DIST-CO-RTE-PM: 06-TUL-63-2.0/4.0
Work Description: FOR CONSTRUCTION ON STATE HIGHWAY IN TULARE COUNTY NEAR VISALIA FROM EAST CARTMILL AVENUE TO AVENUE 264
Location Description: In District 06 On Route 63
Contractor Name: AGEE CONSTRUCTION CORPORATION
Contractor Address: 1039 HOBLITT AVE, CLOVIS, CA 93612
Resident Engineer: Haidar Haddadin Structure Rep.: Unknown
DIME Sample ID: 2023-10-03-52
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: Department Acceptance
Type of Material: Asphalt Rubber Binder
Sample Taken Date: 10/03/2023
Date that the sample was received by the laboratory/organization performing the testing: 10/10/2023
The quantity of what the sample constitutes: 1 of 1 can
A brief description of the sample: PG 64-16
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: deer creek asphalt
Asphalt modifier supplier: DEER GREEK ASPHALT
Performance Grade: PG 64-16
Lot number:
Sublot number:
Asphalt Rubber Binder Mix Number:
