Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214764 DEA: 032H6404 EFIS: 0317000167
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-12,160-0.4/0.9,L10.5/R0.2
Work Description: MODIFY SIGNAL AND LIGHTING SYSTEM, PLACE RHMA AND ROADWAY EXCAVATION.
Location Description: SACRAMENTO COUNTY NEAR RIO VISTA ON ROUTE 12 FROM 0.6 MILE EAST OF SACRAMENTO RIVER BRIDGE TO 5.2 MILES WEST OF MOKELUMNE RIVER BRIDGE AND ON ROUTE 160 FROM 3.6 MILES NORTH OF THREE MILE SLOUGH BRIDGE TO 2.7 MILES SOUTH OF CIRCLE DRIVE
Contractor Name: OC JONES & CO.
Contractor Address: 1520 4th Street, Berkeley, Ca 94710
Resident Engineer: Frank Cannizzaro Structure Rep.: Unknown
DIME Sample ID: 2021-04-05-33
TL Number from the TL Form: C123456
Sample Submitted By Organization: CT D03 - Olivehurst Northern Regional Laboratory
Sample Organization Contact: (530) 741-4238
Type of Sample: Verification
Type of Material: Crumb Rubber Modifier
Sample Taken Date: 04/05/2021
Date that the sample was received by the laboratory/organization performing the testing: 04/06/2021
The quantity of what the sample constitutes: JMF Verification
A brief description of the sample: High Natural - Crumb Rubber Modifier
From where was the sample collected: Manufacturer
Laboratory sample identification: JMF21-011
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: George Reed Inc - Clements Batch Plant
