Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215734 DEA: 024H0104 EFIS: 0218000068
QA Service Level: 1
DIST-CO-RTE-PM: 02-PLU-70-78.3/90.3
Work Description: REPLACE AC SURFACING, PLACE HMA AND THERMOPLASTIC TRAFFIC STRIPING.
Location Description: PLUMAS COUNTY NEAR PORTOLA FROM 0.4 MILE WEST OF BIG GRIZZLY CREEK BRIDGE TO 0.8 MILE WEST OF SUMMIT SCHOOL DRIVE
Contractor Name: HAT CREEK CONSTRUCTION & MATERIALS, INC.
Contractor Address: 243339 Hwy 89, N Burney, CA 96013
Resident Engineer: Mike Zdenek Structure Rep.: Unknown
DIME Sample ID: 2026-05-30-12
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: No Test
Type of Material: Asphaltic Emulsion
Sample Taken Date: 05/30/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/12/2026
The quantity of what the sample constitutes: 1 JUG OF CQSI
A brief description of the sample: CQSI
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: ALBINA
