CDOT Form #1304 04/19Distribution:
COLORADO DEPARTMENT OF TRANSPORTATION
HMA SAMPLE SUBMITTAL Date Submitted
Project No.Contract ID
Reference previously used Contract ID & Form #43 No.:
Region
Prime Contractor HMA Supplier Special Provisions Applicable:( Yes No)
Pit Names Form #43 Date
Item # Test No. Sample Represents Total Quantity Placed
Sampled From (CP 41) Grading Gyrations Binder Plant
Roadway
S SMA 50 100 PG58-28 PG64-28
Other ___________
Windrow
Auger
SX SG 75 125 PG58-34 PG70-28
Other ____________ Other ____________
PG64-22 PG76-28
Yes No
AC & Belt Cut CPL 5120C/CP 85C
Place IA stamp here:
Central LabFlex Lab: _________Euro Lab: _________AMPT Lab: _________
Number of Cans Submitted Sample Location Information
Project Tester (print name) Title
Supervisor (print name) Title E-mail Address
Project Location
Contact Person (QA Tester) Contact phone #
Sample ID for Quality Acceptance:
QA tested at:
Region Lab:
Ticket # Time sampled Station Lane Daily Tons @ Sample
Witnessed by Date sampled Via (state,contractor or courier) Date Shipped Shipped by
E-mail Address
Form #43 Number
Tests - Required as indicated CP 31HMAaa
CPL 5106 CP 48aa
CPL 5115 CP 51 CPL 5120
______________________
CP 85
AcceptanceVoidsGradation
Sample ID for IA
FS# = (Contract ID-Seq.#)
Field Lab:
Region Mobile Lab:
Submit 2 Full Buckets at the request of the Region Material EngineerDo not create Sample record in SMM
____________________________ of this mix to date - ________________________________Tons
CPL 5109 Region LabsEvery 10,000 Tons
CPL 5109 Central Lab
1st 10,000 Tons only
Sample ID for Central Lab / Flex Lab
AMPT
Sample Type must be Information only.
Sample ID for Central Lab / Euro Lab:
Sample Type must be Quality Acceptance
Plan Quality
Sample represents:
Check Testing
Mix Verification
1 per 10,000 ton
Hamburg Rutter CPL 5112French Rutter CPL 5114
ST RCI
Tons
Sample ID Region Lab
Flex Lab: [email protected] Euro Lab: [email protected] Region Lab or Region Mobile Lab Project File: Upload completed Form into the attachment icon on sample record SMM/LIMS only
Electronic Signature of IA Personnel
Previous editions are obsolete and may not be used.
Consultant Lab:
Region Lab:Region Mobile:Consultant:
