ITD 0859 (Rev. 04-10) Performance Graded Binder Sample Identification
itd.idaho.gov
Idaho Transportation Department
Binder Sampled (Grade) Sampled For (Regional/Resident Engineer)
Key Number Project Number Project Name Contract Item Number
Identification Number (Program/Task/Phase) Sampled By (please print) WAQTC Number
Send Results To (Resident Engineer) Address District
Percent Anti-Stripping Additive Req'd. by Contract Percent Added Additive Brand T-99 Tested By WAQTC Number
Refinery Refinery Location
Source Supplier Supplier Location
Weekly Binder Verification Unit
A Daily Binder Sample is comprised of a minimum of 3 individual one-quart cans. Label each of the sample cans with the same identification
number. The Binder Verification Unit represents approximately one week of plant mix production or up to 7 Daily Binder Samples.
*Note: Either the contractor or ITD representative, one of which must be WAQTC qualified, may perform the sampling with both
parties witnessing the sampling. By signing below, the representatives are certifying that they have witnessed the sampling and
the sampling was performed at the mix plant's asphalt tank injection line in accordance with AASHTO T-40.
Identification Date Sample T-99 Test ITD Representative's WAQTC Contractor Representative's WAQTC
Lab Number
Number Sampled Number Pos Neg Signature* Number Signature* Number
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(BL) Number(s)
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(BL) Number(s)
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(BL) Number(s)
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(BL) Number(s)
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(BL) Number(s)
Supplier's Lot Number From the Bills of Lading These Samples are the Last Samples for This Project Central Laboratory Has Been Notified
Yes No Yes No
Remarks
Distribution: Original (White) – With sample to Central Materials
Copy (Yellow) – To Project File with all bills of lading attached
Copy (Pink) – Retained by ITD Inspector