Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001284 DEA: 033J40U4 EFIS: 0325000035
QA Service Level: 1
DIST-CO-RTE-PM: 03-ED-VAR-VAR
Work Description: Combine MMBN 03-3J400, 10-1Q090 Middle-Mile Broadband Network
Location Description:
Contractor Name: TEICHERT ENERGY & UTILITIES GROUP, INC.
Contractor Address: 3500 AMERICAN RIVER DRIVE, SACRAMENTO CA 95864
Resident Engineer: Nathan Alterton Structure Rep.: Unknown
DIME Sample ID: 2026-06-02-40
TL Number from the TL Form:
Sample Submitted By Organization: Blackburn Consulting
Sample Organization Contact: (916) 375-8706
Type of Sample: Preliminary
Type of Material: Hot Mix Asphalt
Sample Taken Date: 06/02/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 12 boxes, 4 buckets, 2 oil cans
A brief description of the sample: JMF Verification
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: South Lake Tahoe Hot Plant
