Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995119 DEA: 034H6004 EFIS: 0319000004
QA Service Level: 1
DIST-CO-RTE-PM: 03-PLA-49-R8.7/R10.6
Work Description: CONC BARRIER, JPCP, HMA, RDWY EXC, RCP AND LIGHTING.
Location Description: PLACER COUNTY NEAR AUBURN FROM 0.3 MILE SOUTH OF LORENSEN ROAD/FLORENCE LANE TO 0.4 MILE NORTH OF LONE STAR ROAD
Contractor Name: DESILVA GATES CONSTRUCTION, LLC
Contractor Address: Unknown
Resident Engineer: Jeff Johnson Structure Rep.: Asia Al Maliki
DIME Sample ID: 2025-10-23-45
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: 10/23/2025
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 2 Boxes
A brief description of the sample: 1/2" RHMA-O, PG 64-16
From where was the sample collected: Manufacturer
Laboratory sample identification: 5945
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Desilva Gates-Marysville
