CDOT Form #1304 04/19 Distribution: 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 Lab Flex 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 Acceptance Voids Gradation Sample ID for IA FS# = (Contract ID-Seq.#) Field Lab: Region Mobile Lab: Submit 2 Full Buckets at the request of the Region Material Engineer Do not create Sample record in SMM ____________________________ of this mix to date - ________________________________Tons CPL 5109 Region Labs Every 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 5112 French Rutter CPL 5114 ST RCI Tons Sample ID Region Lab Flex Lab: cdot_[email protected] Euro Lab: cdot_[email protected] Region Lab or Region Mobile Lab Project File: Upload completed Form into the attachment icon on sample record SMM/LIMS only Previous editions are obsolete and may not be used. Consultant Lab: Region Lab: Region Mobile: Consultant: