Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 44444 DEA: ASCP EFIS: ASCP
QA Service Level:
DIST-CO-RTE-PM: 59---
Work Description: Special project for submitting Sample information for Asphalt Supplier Certification Program.
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2021-07-05-4
TL Number from the TL Form:
Sample Submitted By Organization: Seventeen Twenty Oil Company
Sample Organization Contact: (562) 760-0349
Type of Sample: Quality Control
Type of Material: Asphalt Binder
Sample Taken Date: 07/05/2021
Date that the sample was received by the laboratory/organization performing the testing: 07/08/2021
The quantity of what the sample constitutes: 2 cans split sample
A brief description of the sample: Asphalt Binder Sample
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: 1720
Performance Grade: PG 64-16
Modified: No
Lot number:
Sublot number:
Tank number: 3
Time of sample: 0800
HMA Supplier:
Certified Asphalt Supplier: Seventeen Twenty Oil Company - Corona CA
Multigrade: Yes
Multigrade Type: PG 64-16 / PG 64-10
Asphalt Binder Mix Number:
DIME Test ID: 2021-07-05-4-1
Test Method: AASHTO T228-09r13: Standard Method of Test for Specific Gravity of Semi-Solid Asphalt Materials (Specific Gravity)
Verified Date: 08/19/2021
Date Tested: 07/05/2021
Submitted By Organization: Seventeen Twenty Oil Company
Organization Address: 1385 East 6th Street,
Organization City: Corona
Organization State: CA
Organization Zipcode: 92879
Organization Email: shawn@1720oil.com
Organization Phone: (562) 760-0349
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
