Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214899 DEA: 033H4504 EFIS: 0318000001
QA Service Level: 1
DIST-CO-RTE-PM: 03-ED-50-33.8/34.2
Work Description: CONSTRUCT RW, WIDEN RDWY, COLD PLANE AC PVMT, & HMA OVERLAY.
Location Description: EL DORADO COUNTY AT FRESH POND FROM 0.6 TO 0.2 MILE WEST OF FOREST ROAD/OUTER LIMITS LANE
Contractor Name: BRIDGEWAY CIVIL CONSTRUCTORS, INC.
Contractor Address: 4950 Allison Parkway, # A, Vacaville, CA 95866
Resident Engineer: Jody Phillips Structure Rep.: Dave Carlin
DIME Sample ID: 2022-10-25-22
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: Asphaltic Emulsion
Sample Taken Date: 10/25/2022
Date that the sample was received by the laboratory/organization performing the testing: 10/25/2022
The quantity of what the sample constitutes: 1 Oil Jug
A brief description of the sample: Tack Coat
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Pacific Northwest Oil
