Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995087 DEA: 051P5904 EFIS: 0522000086
QA Service Level: 1
DIST-CO-RTE-PM: 05-SCR-1-0.0/5.0
Work Description: Cold plane, RHMA-G
Location Description: Watsonville area, County line to Scenic pullout
Contractor Name: A. TEICHERT & SON, INC. DBA TEICHERT CONSTRUCTION
Contractor Address: 3500 American River Dr, Sacramento CA 95864
Resident Engineer: Tyler Lavering Structure Rep.: Unknown
DIME Sample ID: 2023-10-08-6
TL Number from the TL Form:
Sample Submitted By Organization: CT D05 - Monterey Construction Field Laboratory
Sample Organization Contact: 831-818-0254
Type of Sample: Quality Assurance
Type of Material: Asphaltic Emulsion
Sample Taken Date: 10/08/2023
Date that the sample was received by the laboratory/organization performing the testing: 10/09/2023
The quantity of what the sample constitutes: 1 JG
A brief description of the sample: SS1H Tack Coat
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: NA
