Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000435 DEA: 030J01U4 EFIS: 0323000244
QA Service Level: 1
DIST-CO-RTE-PM: 03-PLA-28-0.1/11.0
Work Description: HMA (TYPE A), COLD PLANE AC PVMT, RDWY EXC, & CL 2 AB.
Location Description: PLACER COUNTY FROM 0.1 MILE EAST OF ROUTE 89 AT TAHOE CITY TO THE NEVADA STATE LINE AT KINGS BEACH
Contractor Name: MERCER-FRASER COMPANY
Contractor Address: PO Box 1006, Eureka, CA 95502
Resident Engineer: Douglas Hobbs Structure Rep.: Unknown
DIME Sample ID: 2026-06-21-8
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: Asphalt Binder
Sample Taken Date: 06/21/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/22/2026
The quantity of what the sample constitutes: 1 Can
A brief description of the sample: 64-28
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Teichert Martis Valley
Performance Grade: PG 64-28
Modified:
Lot number: 2
Sublot number: 13
Tank number:
Time of sample:
HMA Supplier: Teichert Martis Valley
Certified Asphalt Supplier: Pacific Northwest Oil - Stockton CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
HMA Type:
HMA Supplier Mix ID Number:
