Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994673 DEA: 033F0704 EFIS: 0312000054
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-51-2.0/3.5
Work Description: American River Bridge Rehabilitation
Location Description:
Contractor Name: American River Constructors
Contractor Address: 4001 Bradshaw Road, Sacramento, CA 95827
Resident Engineer: John Ruzic Structure Rep.: Pha Tran
DIME Sample ID: 2025-08-20-47
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: No Test
Type of Material: Asphaltic Emulsion
Sample Taken Date: 08/20/2025
Date that the sample was received by the laboratory/organization performing the testing: 08/22/2025
The quantity of what the sample constitutes: 1 Jug of Emulsion
A brief description of the sample: ss-1h emulsion
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Pacific Northwest Oil
