Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215744 DEA: 033H93U4 EFIS: 0321000091
QA Service Level: 1
DIST-CO-RTE-PM: 03-YUB,BUT-70-25.5/25.8,0.0/3.8
Work Description: WIDEN ROADWAY & SHOULDER, ADD TURN LANES & CONSTRUCT BRIDGE.
Location Description: YUBA AND BUTTE COUNTIES ABOUT 11 MILES NORTH OF MARYSVILLE FROM 0.8 MILE NORTH OF CHANDLER ROAD TO 0.2 MILE SOUTH OF EAST GRIDLEY ROAD
Contractor Name: Teichert Construction & MCM JV
Contractor Address: 4401 Duluth Ave, Rocklin, CA 95766
Resident Engineer: Anthony Granados Structure Rep.: Matt Crete
DIME Sample ID: 2021-09-27-73
TL Number from the TL Form:
Sample Submitted By Organization: CT D03 - Olivehurst Northern Regional Laboratory
Sample Organization Contact: (530) 741-4238
Type of Sample: Verification
Type of Material: Asphalt Binder
Sample Taken Date: 09/27/2021
Date that the sample was received by the laboratory/organization performing the testing: 12/28/2021
The quantity of what the sample constitutes: Cans of oil
A brief description of the sample: Asphalt Binder PG 64-16
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Teichert Quality Assurance
Performance Grade: PG 64-16
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Valero Marketing & Supply - Benicia CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
