Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000365 DEA: 033H9014 EFIS: 0323000075
QA Service Level: 1
DIST-CO-RTE-PM: 03-SOL,YOL-50,80,113-Var
Work Description: HMA, RHMA, SIGN STRUCTURE, CAMERA SYSTEMS, & FO CABLE SYSTEMS.
Location Description: SOLANO AND YOLO COUNTIES AT VARIOUS LOCATIONS
Contractor Name: DESILVA GATES CONSTRUCTION, LLC
Contractor Address: 3855 North Freeway Boulevard, Suite 100, Sacramento, CA 95834
Resident Engineer: Joseph Wild Structure Rep.: Michael Charak
DIME Sample ID: 2025-10-17-16
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: Asphalt Rubber Binder
Sample Taken Date: 10/17/2025
Date that the sample was received by the laboratory/organization performing the testing: 10/21/2025
The quantity of what the sample constitutes: 1 can of rubber
A brief description of the sample: 64-16 rubber
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Valero Benicia
Asphalt modifier supplier:
Performance Grade: PG 64-16
Lot number:
Sublot number:
Asphalt Rubber Binder Mix Number:
