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: Brent Bullard Structure Rep.: Michael Charak
DIME Sample ID: 2026-04-14-25
TL Number from the TL Form:
Sample Submitted By Organization: Mozamo Engineering, Incorporated
Sample Organization Contact: (916) 237-7161
Type of Sample: Quality Assurance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 04/14/2026
Date that the sample was received by the laboratory/organization performing the testing: 04/20/2026
The quantity of what the sample constitutes: 750 Tons
A brief description of the sample: Lot 3 Sublot 8
From where was the sample collected: Distributor
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: DSG Aggregates - Marysville
