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: 2025-10-18-7
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: 10/18/2025
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: 3/4" RHMA-G, PG 64-16
From where was the sample collected: Manufacturer
Laboratory sample identification: 5910
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Desilva Gates-Marysville
