Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001564 DEA: 030J4104 EFIS: 0319000281
QA Service Level: 1
DIST-CO-RTE-PM: 03-PLA-80-33.0/44.9
Work Description: COLD PLANE AC PVMT, HMA, CLASS 2 AB, RDWY EXC, MGS, & RCP.
Location Description: PLACER COUNTY IN AND NEAR COLFAX FROM 0.1 MILE WEST OF ROUTE 174/80 SEPARATION TO 0.1 MILE EAST OF ALTA ROAD UNDERCROSSING
Contractor Name: A. TEICHERT & SON, INC. DBA TEICHERT CONSTRUCTION
Contractor Address: 4401 Duluth Ave, Rocklin, CA 95765
Resident Engineer: Brigette Haddock Structure Rep.: Unknown
DIME Sample ID: 2026-06-23-7
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: 06/23/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/23/2026
The quantity of what the sample constitutes: 1 Can
A brief description of the sample: PG 58-22
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: PNW
Performance Grade: PG 58-22
Modified: No
Lot number: 1
Sublot number: 5
Tank number:
Time of sample: 17:30
HMA Supplier: Teichert Hallwood
Certified Asphalt Supplier: Pacific Northwest Oil - Stockton CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number: 30940132416P
