Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002568 DEA: 033G7604 EFIS: 0325000107
QA Service Level: 1
DIST-CO-RTE-PM: 03--ED-193-0.0/R6.0
Work Description: 0.15' Cold Plane and HMA
Location Description: In El Dorado County near Cool from Route 49 Junction to 1.0 Mile West of Greenwood
Contractor Name: George Reed
Contractor Address: 900 West Elkhourn Blvd, Rio Linda, CA 95673
Resident Engineer: Robert Ericksen Structure Rep.: Unknown
DIME Sample ID: 2026-10-05-10
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: 10/05/2026
Date that the sample was received by the laboratory/organization performing the testing: 10/05/2026
The quantity of what the sample constitutes: 1 CAN OIL
A brief description of the sample: PG 64-16
From where was the sample collected: Manufacturer
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: George Reed Rio Lina
Performance Grade: PG 64-16
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier: George Reed Rio Lina
Certified Asphalt Supplier: VSS Emultech - West Sacramento - West Sacramento CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
HMA Type: 3/4 HMA-A R15
HMA Supplier Mix ID Number: 21100
