Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994929 DEA: 034J6804 EFIS: 0323000228
QA Service Level: 1
DIST-CO-RTE-PM: 03-YOL-128-1/6
Work Description:
Location Description:
Contractor Name: A. TEICHERT & SON, INC. DBA TEICHERT CONSTRUCTION
Contractor Address: 24207 County Road 100A, Davis CA 95617
Resident Engineer: Nimi Badwalz Structure Rep.: Brent Bullard
DIME Sample ID: 2023-12-15-29
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: N/A
