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: 2023-12-04-33
TL Number from the TL Form: 332
Sample Submitted By Organization: CT D05 - Monterey Construction Field Laboratory
Sample Organization Contact: 831-818-0254
Type of Sample: Verification
Type of Material: Asphalt Rubber Binder
Sample Taken Date: 12/04/2023
Date that the sample was received by the laboratory/organization performing the testing: 12/05/2023
The quantity of what the sample constitutes: 1 Can
A brief description of the sample: 64-16 ARB
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: National Blending Company
Asphalt modifier supplier: San Joaquin Refining Co Inc
Performance Grade: PG 64-16
Lot number: 1
Sublot number: 26
Asphalt Rubber Binder Mix Number: 23_1354
