CDOT Form 1304 "Hma Sample Submittal" - Colorado

What Is CDOT Form 1304?

This is a legal form that was released by the Colorado Department of Transportation - a government authority operating within Colorado. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2019;
  • The latest edition provided by the Colorado Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of CDOT Form 1304 by clicking the link below or browse more documents and templates provided by the Colorado Department of Transportation.

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Download CDOT Form 1304 "Hma Sample Submittal" - Colorado

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