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: 2020-12-16-2
TL Number from the TL Form:
Sample Submitted By Organization: Veleroo - Coolidge
Sample Organization Contact: 111-111-1111
Type of Sample: Aggregate Prequalification Program
Type of Material: Asphalt Binder
Sample Taken Date: 12/16/2020
Date that the sample was received by the laboratory/organization performing the testing: 12/15/2020
The quantity of what the sample constitutes: 1
A brief description of the sample: sdfsdf
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: aadf
Performance Grade: PG 58-16
Modified: No
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier:
Multigrade:
Multigrade Type:
Asphalt Binder Mix Number:
DIME Test ID: 2020-12-16-2-1
Test Method: AASHTO T201-15: Standard Method of Test for Kinematic Viscosity of Asphalts (Bitumens) (Original)
Verified Date: 12/17/2020
Date Tested: 12/17/2020
Submitted By Organization: Veleroo - Coolidge
Organization Address: 123 Abc Street,
Organization City: Coolidge
Organization State: AZ
Organization Zipcode: 88888
Organization Email: binderlab1@gmail.com
Organization Phone: (111) 111-1111
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
