Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1 DEA: 01079734 EFIS: 0100020445
QA Service Level: 1
DIST-CO-RTE-PM: 01-VAR--VAR
Work Description: SIGNS, ALUMINUM, LAMINATED & FORMED, ROADSIDE AND OVERHEAD APPLICATIONS
Location Description: Statewide
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2024-04-24-9
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 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
Performance Grade: PG 58-16
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: AASHTO resource
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
