Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000004 DEA: 033H5604 EFIS: 0318000014
QA Service Level: 1
DIST-CO-RTE-PM: 03-PLA,NEV-20,80-VAR
Work Description: STRUCTURAL CONC, BAR REINFORCING STEEL, BRIDGE REMOVAL, HMA, AND JPCP.
Location Description: PLACER AND NEVADA COUNTIES NEAR CISCO GROVE ON ROUTE 80 FROM 0.4 MILE WEST OF LAKE VALLEY OVERCROSSING TO 0.9 MILE EAST OF YUBA PASS SEPARATION AND OVERHEAD AND ON ROUTE 20 AT YUBA PASS SEPARATION AND OVERHEAD
Contractor Name: FLATIRON WEST INC.
Contractor Address: 1200 Concord Ave Suite 465, Concord, CA 94520
Resident Engineer: Tad Sampson Structure Rep.: James 'Jimmer' Ross
DIME Sample ID: 2025-04-16-19
TL Number from the TL Form:
Sample Submitted By Organization: Blackburn Consulting
Sample Organization Contact: (916) 375-8706
Type of Sample: Quality Assurance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 04/16/2025
Date that the sample was received by the laboratory/organization performing the testing: 04/18/2025
The quantity of what the sample constitutes: 2 Boxes
A brief description of the sample: 3/4" HMA-SP w/ 25% RAP, PG 58-22
From where was the sample collected: Source
Laboratory sample identification: 4974
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Teichert Hallwood
