Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994553 DEA: 032G7204 EFIS: 0322000151
QA Service Level: 1
DIST-CO-RTE-PM: 03-YOL-113-R10.1/R10.8
Work Description: JOINTED PLAIN CONC PVMT, INDIVIDUAL SLAB REPL, & REMOVE CONC PVMT.
Location Description: YOLO COUNTY IN WOODLAND FROM 0.1 MILE SOUTH OF EAST WOODLAND OVERHEAD TO 0.1 MILE SOUTH OF S5/S113 CONNECTOR UNDERCROSSING
Contractor Name: FBD VANGUARD CONSTRUCTION INC
Contractor Address: Unknown
Resident Engineer: Jody Phillips Structure Rep.: Unknown
DIME Sample ID: 2023-12-15-28
TL Number from the TL Form:
Sample Submitted By Organization: Blackburn Consulting
Sample Organization Contact: (916) 375-8706
Type of Sample: Quality Assurance
Type of Material: Hot Mix Asphalt
Sample Taken Date: 12/15/2023
Date that the sample was received by the laboratory/organization performing the testing: 12/15/2023
The quantity of what the sample constitutes: 2 HMA Boxes
A brief description of the sample: 3/4" HMA-SP
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Teichert Woodland
