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: Mirak Mehari Structure Rep.: Michael Charak
DIME Sample ID: 2026-04-04-1
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: 04/04/2026
Date that the sample was received by the laboratory/organization performing the testing: 04/04/2026
The quantity of what the sample constitutes: 2 Boxes
A brief description of the sample: 3/4" WMA Type A 15% RAP
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Teichert Woodland
