Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 99999 DEA: 0322222
QA Service Level:
DIST-CO-RTE-PM: 03-SAC,OMG-888,99,80-0.6-0.6
Work Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Location Description: THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS - DATA SUBMITTED FOR THIS PROJECT SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Michael Maksimovich Structure Rep.: Unknown
DIME Sample ID: 2024-04-24-8
TL Number from the TL Form:
Sample Submitted By Organization: ZZCT DIME Development Laboratory A - Bellflower - Internal
Sample Organization Contact: (213) 555-1212
Type of Sample: Verification
Type of Material: Asphalt Rubber Binder
Sample Taken Date: 04/24/2024
Date that the sample was received by the laboratory/organization performing the testing: 04/24/2024
The quantity of what the sample constitutes: 1
A brief description of the sample: 1
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: 1
Asphalt modifier supplier:
Performance Grade: PG 58-22
Lot number:
Sublot number:
Asphalt Rubber Binder Mix Number:
