Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214572 DEA: 034E62U4 EFIS: 0319000068
QA Service Level: 1
DIST-CO-RTE-PM: 03-ED-50-18.5/24.2
Work Description: CONSTRUCT UC, MED BARRIER, DRAINAGE SYSTEMS & HMA OVERLAY.
Location Description: EL DORADO COUNTY IN AND NEAR PLACERVILLE FROM MOSQUITO ROAD UNDERCROSSING TO SCHNELL SCHOOL ROAD UNDERCROSSING AND FROM 0.2 MILE WEST OF STILL MEADOW ROAD TO 0.2 MILE EAST OF CARSON ROAD
Contractor Name: SECURITY PAVING COMPANY, INC.
Contractor Address: 3075 Townsgate Road, Suite 200, Westlake Village, CA 91361
Resident Engineer: Nathan Alterton Structure Rep.: Raymond Macy
DIME Sample ID: 2022-08-23-21
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: 08/23/2022
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: 2 boxes HMA
A brief description of the sample: 3/4 HMA
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Teichert-perkins
