REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS

ANTIQUE
DISTRICT ENGINEERING OFFICE
SAN JOSE, ANTIQUE

SAMPLE CARD
PROJECT ID : 20GB-0004
PROJECT : MALANDOG-BUHANG RD-K0093+296-K0095+000, K0095+774-K0095+780
(Name) (City/Province)
KIND OF MATERIAL : COMPOSITE AGGREGATES 3/4 MAX. SIZE
SAMPLE IDENTIFICATION : ABR-310-01
QUANTITY REPRESENTED : 1500 cu.m.
SAMPLED AT : Jobsite
(Give accurate location if possible)

ORIGINAL SOURCE : Sibalom, Antique

OWNER/SUPPLIER : IBC- International Builders Corporation
SAMPLED/CAST BY : Aladdin Martin P. Deza - ME/DPWH Antique - Leibnitz T. Aurelio-MLT/IBC
(Name of authorized representative) (Signature)

ME / MLT DPWH Antique/IBC February 10, 2020

(Designation) (Office) (Date)

Proposed Use : ITEM 310 - BITUMINOUS CONCRETE SURFACE WEARING COURSE, HOT-LAID (50mm)
Test Desired : Quality test
Governing Specification : AASHTO T-93
Shipped By : Leibnitz T. Aurelio-MLT IBC February 10, 2020
(Name & Designation) (Office) (Date)

Send Test Results to :

(Mailing Address)
REMARKS :
:
Bill Charged To : IBC- International Builders Corporation
Submitted by : Aladdin Martin P. Deza - Materials-In-Charge
(Name and Date) (Signature)

: DPWH ANTIQUE DEO San Jose, Antique

( Office ) ( Mailing Address )
OK AS TO SAMPLE :
Date :

OR #_____________________Date:_________________________

RECEIVED BY: _______________________________ LAB. NO.

DUE DATE:

NOTED: ROBERTO RIZAL P. PALANOG

Project Engineer/DPWH Antique DEO