QUESTIONNAIRE

EVALUATION OF HIGH PERFORMANCE BITUMINOUS PREMIX

1. Producer:                                                                                      Contract No.:

2.   Date Received:                                                                             Location:

3. Condition of material at time of delivery:

A. Quantity Received:

B.   Did material contain ice crystals or water?                                        Y          N

1) If so, how much?  (Circle number 1-5 below.)

Insignificant Amount - 1     2      3      4      5    - Highly Significant Amount

C.  Was material contaminated?                                                              Y          N

1) If so, with what?

a) Dust

b) Limestone

c) Sand

d) Other (Specify):

e) Unknown (Describe):

D.  Did material contain lumps?                                                               Y          N

1) If so, how much?  (Circle number 1-5 below.)

Insignificant Amount - 1     2      3      4      5    - Highly Significant Amount

E.   Was material fully coated with a shiny black appearance?               Y          N

1) If not, describe condition.

4. Storage of Material

A. How was material stockpiled?

B.   Was stockpile kept covered?                                                             Y          N

1) If yes, how?

C.  Did a hard crust form on the stockpile?                                             Y          N

1) If yes, how thick was the crust?

D.  Did material change appearance?  (For example, change from shiny black to dull brown?)

                                                                                                                  Y          N

1) If yes, describe change in appearance.

E.   How long was material in stockpile before use?

5. Performance of Material

A.   Was material usable in cold weather?                                                Y          N

1) Approximately, in what temperature range was it used?

B.   Did material stick in patch area?                                                        Y          N

1) Was patch area wet or dry?

C.  Did material stay put under traffic?                                                    Y          N

1)   If not, did material:

a) Track bituminous oil

b) Crumble and scatter

c) “Pop out” of patch in large chunks

d) Deform or move

D.  Was material heated or warmed prior to use?                                   Y          N

1) If yes, how?

E. Overall performance rating (Circle number 1-5 below.)

Very Poor     Poor      Average      Good      Excellent

1                2             3                  4               5

F.   Comments