Appendix I

Instructions for completing a TE-10 Form

Form TE-10 Sample Data Shipping Tag (Front)

FIELD NAME INSTRUCTIONS
Sample ID

(Front)

Provided by CMS upon entry
Material Code CMS code for the material
Remarks Any special instruction or comments for testing

Form TE-10 Concrete Cylinder Sample Data Shipping Tag (Back)

FIELD NAME INSTRUCTIONS
Sample ID

(Front)

Provided by CMS upon entry
Project/P.O. The Project or P.O. number where the material is to be assigned (used)
County Name or three digit abbreviation for county location of project or P.O.
Class of Concrete Class name for the concrete represented by the sample
Date Made The date the sample was taken
Cylinder Specimen # Number assigned to the cylinder by the project

Appendix I

Instructions for completing a TE-30 Form

Form TE-30

FIELD NAME INSTRUCTIONS
Field Inspection of: See Appendix (D) for appropriate TE-30 Supplemental
Sample ID Provided by CMS upon entry of TE-30
Personnel ID CMS ID number of the person performing the inspection of the material.
Type of Inspection Identifies the primary method used for approving the material. (i.e. Small Quantities, Certified Test Data, etc)
Date Sampled The date the inspection was performed
P/S Code CMS code for the Producer/Supplier providing the material. (If Producer/Supplier code is unknown, provide name and location.)
Material Code CMS code for the material. (If material code is unknown, provide a description of the material.)
Brand Name The Brand Name of the material. (See material code in CMS to determine if required.)
Desc #1 Provides a further break down of the material.
Desc #2 / #3 (i.e. dimensions, color, etc.-see material codes in CMS for requirements)
Rep. Quantity The quantity of the material represented by the TE-30
Unit of Measure The unit of measure of the Represented Quantity. (i.e. Ton, Linear Feet)
Items The number of items represented. Some material may be in lbs., linear feet, etc. and it is desirable to identify the quantify as to the number of items represented.
Sampled From On the TE-30 this identifies the location where the material was inspected. (i.e. project site, contractor warehouse, etc.)
Mfg. Control No. If provided, the lot, batch or other identifying marking of the material. (Some materials require this information-see material codes in CMS for requirements.)
Bill Lading/Ticket Provide the identification of the shipping document.
Standard Drawing Identifies the drawing or plan page number that describes the material requirements.
Project/P.O. The number (identifier) of the project or purchase order where the material is to be assigned (used)
P.O. Ind. If the Project/P.O. number is a Purchase Order number, enter a "Y" in the Purchase Order Indicator field.
Item Code The Item Code within the Project/P.O. where the material is to be used.
Ref. Number The Reference Number within the Project/P.O. where the materials is to be used
Quantity The portion of the Represented Quantity to be assigned to the specified item code and Reference Number.

Appendix I

Instructions for completing TE-31 Form

Form TE-31

FIELD NAME INSTRUCTIONS
Envelope # The number of the envelope (attached) enclosed with the sample that will contain the TE-31
Sample ID Provided by CMS upon entry of TE-31
Sample Origin Identifies where tracking and test completion reports are to be sent. If sample is for a District/Project, put in district number. If sample reporting is for TL only, put in "LL"
Personnel ID CMS ID number of the person performing the inspection of the material
Type of Inspection Identifies the type of inspection to be performed.(i.e.,Job Control-CTL, check independent assurance sample IAS, quality-QAL)
Date Sampled The date the sample was taken
P/S Code CMS code for the Produce/Supplier providing the material. If Producer/supplier code is unknown, provide name and location.
Mix Plant Bituminous or Portland Cement Concrete Plant where the material being sampled is to be used in mix. (Only used for those materials sampled by plant-i.e., cement and fly ash.)
Material Code CMS code for the material. (If material code is unknown, provide a description of the material)
Brand Name The Brand Name of the material. (See material code in CMS to determine if required.
Desc #1 Provides a further break down of the material when aggregate material code starts with 07 specification goes here
Desc #2 / 3 (i.e.) Dimensions, color, etc.-see material codes in CMS for requirements.)
Rep. Quantity The quantity of the material represented by the TE-31. (Required if job Control sample.)
Unit of Measure The unit of measure of the Represented Quantity. (i.e. ton, linear feet etc)
Number of Items The number of items represented. Some material may be in lbs., linear feet, etc. and it is desirable to identify the quantity as to the number of items represented
Consigned To The name of the company to which the material is being consigned
Sampled From Identifies where the sample was obtained. (i.e. barge, tank car, tank, stock pile drum, etc.

Appendix I

Instructions for completing TE-31 Form

Form TE-31

FIELD NAME INSTRUCTIONS
Mfg. Control No. The manufacturers control number-lot number, batch number, etc. (Some materials require this information-see material codes in CMS for requirements)
Responsible Location If the District is to perform the test, provide the District Number. If the OMM is to perform the test provide "TL".
Test Lab Identifies the Lab that will be performing the test.
Project/P.O. The number (Identifier) of the project or purchase order where the material is to be assigned / related to. (i.e. if Job control, check sample or IAS)
P.O. Ind If the Project / P.O. number is a Purchase Order number, enter a "Y" in the Purchase Order Indicator Field.
Item Code The Item code within the Project / P.O. where the material is to be used.
Ref. Number The Reference Number within the Project / P.O. where the material is to be used.
Quantity The portion of the Represented Quantity to be assigned to the specified Item code and Reference Number.
Lot/Day If the sample is for 441 materials, identify the Lot/Day number
JMF if the sample is for a Bituminous concrete material, identify the JMF number used to produce the material. (Rice or Extraction Samples)
Concrete Cylinder If the sample is of concrete cylinders, this Specimen Numbers: is the Specimen number of the concrete cylinders applied when the cylinders were created in the field.
Bill of Lading No. Provide the identification of the shipping document. (Required for Cement Samples)

Appendix I

Instructions for completing TE-37 Form

Form TE-37 Bituminous Concrete Extraction Work Sheet

FIELD NAME INSTRUCTIONS
Sample ID Sample ID number assigned to the Sample when the TE-31 attached to the Sampled was entered. Various District Labs requested some sample data accompany the work sheet. Therefore, the fields are provided for their use. (This data will be on the TE-31 as well as in CMS)
Is Material 448 If the material being tested is a Bituminous Concrete 448 material, identify as a Y (yes). (This enables CMS to identify the test to be used in the Outlier Process and "448" payments.)
Individual Bowls could be up to 4 bowls for individual calculations.
Composite The total of all four bowls
Uncorrected Bitumen Sample gross subtract extracted aggregate divided back into sample gross
Reflux secondary absorption test. See work sheet.
Nuclear Gauge A.C. Asphalt content obtained by nuclear gauge
Effluent (ml) The amount of solvent ran through the centrifuge and captured after cleaning the sample.
Ash Per 100 ml The amount of mineral dust in a 100 ml crucible.
Mineral In Effluent Total amount of mineral dust in the solvent.
Sample Gross The total weight of the sample of mix.
Extracted Aggregate The dry weight of the aggregate after the AC is removed from the mix.
Net wt. of Aggregate The dry weight of the total amount of aggregate after adding the mineral dust from extraction lost.
Retained Amount of material on each sieve. (Grams)
% Pass Percent passing each sieve. Net wt. of aggregate minus grams retained on each sieve divided back into net weight of aggregate equals percent passing each sieve.
Grams Accumulative amounts of grams retained on each sieve.
Corrected Bitumen Sample gross subtract net wt. of aggregate divided back into gross sample weight.

Appendix I

Instructions for completing a TE-45 Form

TE 45 Concrete Inspector's Daily Report

FIELD NAME INSTRUCTIONS
Sample ID provided by CMS upon entry of TE-45.
Personnel ID CMS ID number of the person performing the tests reported on the TE-45.
Type of Inspection Identifies the type of inspection that the TE-45 represents. (Normally job control.)
Date Sampled The date the inspection was performed. (i.e. the date the concrete was poured
P.S. Code CMS code for the producer providing the material. (If Producer/Supplier code is unknown, provide name and location)
Material Code CMS code for the material. (If material code is unknown, provide a description of the material.)
Rep. Quantity the quantity of the material represented by the TE-45 (the total of the quantity poured (used) for the day represented by the TE-45
Project/P.O. The number (identifier) of the project or purchase order where the material is to be assigned (used)
P.O. Ind If the Project / P.O. number is a Purchase Order number, enter a "Y" in the Purchase Order Indicator field.
Item Code The item Code within the Project / P.O. where the material is to be used (Multiple items may be identified.)
Ref. Number The Reference Number within the Project / P.O. where the material is to be used. (Multiple Reference Nos. may be identified.)
Quantity the portion of the Represented Quantity to be assigned to the specified Item code and Reference Number.
Test Results Identify whether the air, slump and yield is acceptable or not.
Cylinder or Beam

Indicator

Enter a "B" or a "C"if a beam or cylinder was created along with the associated air / slump / yield data.
Cylinder or Beam

Specimen

The ID number for the set of cylinders or Number: beams created. (i.e. 1A and 1B or whatever system is used. Maximum number could be 999A and 999B.)

For explanation of use for the rest of the form, refer to the construction Manual of Procedures for Concrete.

Appendix I

Instructions for completing TE-67 Form

Form TE-67 Gradation Test

FIELD NAME INSTRUCTIONS
Sample ID Provided by CMS upon entry of TE-67 or TE-31 if sample is sent to District
Personnel ID CMS ID number of the person performing the test of the material
Type of Inspection Identifies the type of inspection that the sample test represents. (i.e. check sample / control sample)
Date Sampled The date the sample was obtained
P / S Code CMS code for the Producer / supplier providing the material. (If Producer / supplier code is unknown, provide name and location.)
Mix Plant Producer Bituminous or Portland cement Concrete Plant where material was sampled and tested for subsequent use in a mix.
Material Code CMS code for the material. (If material code is unknown, provide a description of the material.
Rep. Quantity the quantity of the material represented by each SID# Prefix & Suffix
Consigned To The name of the company to which the material is being consigned. (If it is being consigned.)
Sampled From This identifies where the material was taken. (Normally will be a stock

pile identifier (i.e., number, letter, etc.)

Mfg Control No. When physical sample is sent to Columbus for testing G# is entered by Columbus her.
Project / P.O. The number (identifier) of the project or purchase order where the material is to be assigned or related to. (Assigned if Job control, related to if check or Independent Assurance.) If these are plant samples then projects are not identified.)
P.O. Ind If the Project / P.O. number is a Purchase Order number, enter a "Y" in the Purchase Order Indicator Field.

This TE-67 form can be used as a worksheet for field tests or for tests run in the district and /or OMM.

The difference in use will be that samples collected and sent to the District or OMM will be accompanied by a TE-31 Sample data Form. The top portion of this form from Personnel ID through Assign To fields will only be filed in for gradation tests performed in the field or at P/S location. (i.e. Daily Stock samples)

Appendix 1

Instructions for completing TE-37 Form

Form TE-67

FIELD NAME INSTRUCTIONS
Item Code The Item code within the Project / P.O. where the material is to be used.
Ref. Number The Reference Number within the Project / P.O. where the material is to be used.
Quantity The portion of the Represented Quantity to be assigned to the specified SID Suffix & Prefix based on Item Code and Reference Number
Sieve Analysis
Value A Is the oven dry weight of any sample
Value B Is the wash oven dry weight of a sand
Value C Is the weight passing the No. (4) sieve of a dense graded material
Value D Is the oven dry weight of the Split portion of minus (4) material used in the gradation calculation of the minus (4) fraction of a dense graded material
Value E Is the oven dried weight of the plus (4) fraction used for the determination of the amount passing the No. (200) sieve of the plus (4) fraction of a dense graded material
Value F Is the washed oven dried weight of the plus (4) fraction used for the determination of the amount passing the No. (200) sieve of the plus (4) fraction of a dense graded material
Value G Is the washed oven dry weight of the Split portion of minus (4) material used in the gradation calculation of the minus (4) fraction of a dense graded material
  Enter the spec year of the project that the material will be assigned. If no project involved, enter desired Spec year.
  Enter the sieve weights retained on line opposite the appropriate sieve
CA P-200 When a coarse aggregate being graded is intended for use in concrete. The value of the P-200 of the coarse aggregate in this field
FA P-200 the P-200 of the companion sand for the above coarse aggregate described above (CA P-200)
Sample ID Provide the sample ID of the companion sand for the coarse aggregate described above.

Provide the rest of data on the form if appropriate based upon the tests performed.

Appendix I

Instructions for Completing TE-125

Form 125 Bituminous Concrete Plant Report

FIELD NAME INSTRUCTIONS
Sample ID Provided by CMS upon entry of TE-125.
Personnel ID CMS ID number of the person performing the inspection of the material.
Type of Inspection Identifies the type of inspection. (Normally on a TE-125 it will be a Job Control)
Date Sampled The date the inspection was performed.
P / S Code CMS code for the Producer / Supplier providing the material. (If Producer / Supplier code is unknown, provide name and location.)
Material Code CMS code for the material. (If material code is unknown, provide a description of the Material)
Rep. Quantity The quantity of the material represented by the TE-125.
Project / P.O. The number (Identifier) of the project or purchase order where the material is to be assigned (used)
P.O. Ind. If the Project / P.O. number is a Purchase Order number, enter a "Y" in the Purchase Order Indicator field.
Item Code The Item Code within the Project / P.O. where the material is to be used.
Ref. Number The Reference Number within the Project / P.O. where the material is to be used.
Quantity The portion of the Represented Quantity to be assigned to the specified item Code and Reference Number
JMF Job mix formula identification number.
Weather Type of weather that day. (i.e. cloudy, rainy, etc)
Air Temp Min,-lowest temp that day max-highest temp that day
Plant start up Time of day production started up.
Shut Down Time of day production stop.

Appendix I

Instructions for completing TE-125 Form

Form TE-125

FIELD NAME INSTRUCTIONS
Production hours Total amount of time the asphalts plants dryer was running. (Drier Time)
Time Time fo day sample or temp was taken
A.C. Temp Temp of liquid asphalt
Mix Temp Temp of asphalt mix.
Cold Bin Data Need the percent for each material being run through the cold feeders. Total percent should equal 100 percent.
Hot Bin Data Need the percent of each hot bin being used and the percent of asphalt concrete. The total of all bins plus the asphalt content should equal 1000 percent.
Screen Opening Size of screens in each hot bin. (inches)
Pounds per batch Need the pounds of material in each hot bin plus the pounds of asphalt cement. The total will be the batch size which is being made.
Carry-over Analysis of Bins Time of hot bin taken and the calculation of the total percent passing the number four sieve.
Combined Gradations In a batch plant, it's the total of all hot bins graded through a specified sieve arrangement. In a drum mix plant, it's the total of all cold feed bins graded through a specified sieve arrangement.
A.C. Scale 50lb test weights are put on the AC weight bucket one at a time until the weight exceeds the asphalt optimum being pulled for a particular mix
Tested By The inspectors name
Test Results Test data approved or not approved.

Appendix I

Instructions for completing TE-199 Form

Form TE-31 Contractors Quality control Report for Bituminous Concrete

FIELD NAME INSTRUCTIONS
Sample ID Provided by CMS upon entry of TE-199
Personnel ID CMS ID number of the state person responsible for this P/S and related documents.
Type of Inspection Identifies the type of inspection. (Normally these will be check Samples)
Date Sampled The date the inspection was performed. (Since a TE-199 for 448 materials may cover multiple days-last day represented)
P/S Code CMS code for the Producer / Supplier providing the material. (If Producer/Supplier code is unknown, provide name and location)
Material Code CMS code for the material. (If material code is unknown, provide a description of the material.)
Rep Quantity The quantity of the material represented by the TE-199.
Project / P.O. The number (identifier) of the project or purchase order where the material is to be assigned (used) (Only one project or P.O. can be contained on one TE-199.
P.O. Ind If the Project /P.O. number is a Purchase Order number, enter a "Y" in the Purchase Order Indicator field.
Item Code The item code within the project / P.O. where the material is to be used
Ref. Number the Reference Number within the Project / P.O. where the material is to be used.
JMF Job Mix formula Identification Number.
Lot/Day Number If 446 material, this will be the Day number. If 448 material, this will be the Lot number. (It could identify a sub lot-i.e.1A, 1B, etc)
Test Results Test data approved or not approved.

Appendix I

Instructions for completing TE-217

Form TE-217 Bituminous Concrete Density Determination

FIELD NAME INSTRUCTIONS
Sample ID Provided by CMS upon entry of TE-217.
Personnel ID CMS ID number of the state person responsible for this P/S and related documents.
Type of Inspection Identifies the type of inspection. (Normally this will be job control could be check or IAS)
Date Sampled The date the cores were taken
P/S Code CMS code for the Producer/Supplier providing the material. (If Producer/Supplier code is unknown, provide name and location)
Material Code CMS code for the material. (If material code is unknown, provide a description of the material)
Rep Quantity The quantity of the material represented by the TE-217. (If job control)
Project / P.O. The number (identifier) of the project or purchase order where the material is to be assigned (used). (Only one project or P.O. can be contained on one TE-217)
P.O. Ind If the Project / P.O. number is a purchase order number, enter a "Y" in the purchase order indicator field.
Item Code The item code within the project / P.O. where the material is to be used
Ref. Number The Reference Number within the Project / P.O. where the material is to be used.
Quantity The portion of the Represented Quantity to be assigned to the specified item code and reference number.
JMF Job Mix formula identification number.
Lot/Day Number If 446 material, this will be the Day number. If 448 material, this will be the Lot Number. (It should be sub-lot number or sublots-1A,1B, 2A, etc)

Appendix I

Instructions for completing TE-220 Form

Form TE-220 Bituminous Concrete Rice Worksheet

FIELD NAME INSTRUCTIONS
Sample ID Provided by CMS upon entry of TE-31 that accompanies the Rice Sample
Project or P.O. The number that the project is given identification.
JMF The number given a certain mix type on the project.
Material i.e. mix type 448-I, 448-II, 301, 402, etc
Lot/Day No. In reference to the TE-199, 448 projects measured in lots of 3000 tons, 446 are days of production.
Bitumen Content The amount of asphalt cement in a bituminous mixture.
Contractor MSG The maximum specific gravity the contractor obtained during their testing of an un-compacted mixture
Dry Weight of Mix The weight of material being tested
Weight of container & water The weight of the flask filled to the calibration point with water.
Weight of Container Mix & W. The weight of the flask with the amount of test material inside filled with water
Saturated Surface Dry Weight The weight of the mix after taking account the moisture which was absorbed into the mix during testing.
MSG Maximum specific gravity of an un-compacted bituminous mix
Remarks A note of any irregularities during testing.
Test Results Tests are approved or not approved.

Appendix I

Instructions for completing TE-221 Form.

Form TE-221 Bituminous Concrete Marshal Specimen

FIELD NAME INSTRUCTIONS
Sample ID Provided by CMS upon entry of TE-221
Personnel ID CMS ID number of the person performing the inspection of the material
Type of Inspection Identifies the type of inspection represented by the document. (Normally will be a check sample might be an IAS.)
Date Sampled The date the P / S testing was performed.
P/S Code CMS code for the Producer / Supplier providing the material. (If Producer/Supplier code is unknown, provide name and location.)
Material Code CMS code for the material. (If material code is unknown, provide a description of the material.)
Project / P.O. The number (identifier) of the project or purchase order where the material is to be assigned (used). (Only one Project / P.O. will be related to a set of test)
P.O. Ind If the Project/P.O. number is a Purchase Order number, enter a "Y" in the Purchase Order Indicator field.
Item Code The Item Code within the Project/P.O. where the material is to be used.
Ref. Number The Reference Number within the Project / P.O. where the material is to be used.
JMF The number given a certain mix type on the project.
Lot/Day No In reference to the TE-199, 448 projects are measured in lots of 3000 tons, 446 projects are days of production.
AC % Design The percent of asphalt cement that is in a given asphalt mix.
Compaction Temp The temp at which the Marshall pill was compacted.
Weight in Air The weight of the Marshall pill after cooling and before testing.

Appendix I

Instructions for completing TE-221 Form

Form TE-221

FIELD NAME INSTRUCTIONS
Saturated Surface Dry Weight The weight of specimen after testing in water and after blotting surface dry. (Weight of specimen taking into account absorbed moisture during test)
Weight in Water The weight of the pill while being suspended in a water bath.
Volume The amount of water displaced by the pill in the water bath.
Actual Specific Gravity the specific gravity of a compacted Marshall pill.
Max Theo. specific gravity Maximum specific gravity of an un-compacted mix.
% Voids The percent of air voids in a compacted Marshall pill.
Average Specific Gravity The average of (2) or more Marshall pill gravities.
Contractor Results The percent of air voids on a comparison set of pills tested by the contractor
RAP Recycled asphalt pavement used as an aggregate in asphalt hot mixes.
District Results The percent of air voids as tested by the district lab on a set of Marshall pills.
Remarks A note of any irregularities during testing.