Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 213411 DEA: 030H10U4 EFIS: 0317000246
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-5-9.7/24.9
Work Description:
Location Description: Construction on state highway in Sacramento County in and near Sacramento from 1.1 miles south of Elk Grove Boulevard to American River Viaduct
Contractor Name: NOR CAL PAVING TEICHERT/GRANITE
Contractor Address: 400 Sunrise Ave. Ste. #300, Roseville, CA 95661
Resident Engineer: Daniel Tecle Structure Rep.: Pha Tran
DIME Sample ID: 2022-07-21-27
TL Number from the TL Form:
Sample Submitted By Organization: Blackburn Consulting
Sample Organization Contact: (916) 375-8706
Type of Sample: Quality Control
Type of Material: Hot Mix Asphalt
Sample Taken Date: 07/21/2022
Date that the sample was received by the laboratory/organization performing the testing: 07/21/2022
The quantity of what the sample constitutes: 2 boxes
A brief description of the sample: 1/2" RHMA-0
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Teichert Perkins
