Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994975 DEA: 034H0704 EFIS: 0318000158
QA Service Level: 1
DIST-CO-RTE-PM: 03-NEV-20-R12.2/20.0
Work Description: COLD PLANE AND OVERLAY, INSTALL CURED-IN-PLACE PIPELINERS.
Location Description: NEVADA COUNTY IN AND NEAR GRASS VALLEY AND NEVADA CITY FROM ROUTE 20/49 SEPARATION TO 0.1 MILE EAST OF CELIO ROAD
Contractor Name: DESILVA GATES CONSTRUCTION LLC
Contractor Address: 3855 N Freeway, Ste. 100, Sacramento, CA 95834
Resident Engineer: Renee Plaza Structure Rep.: Unknown
DIME Sample ID: 2024-08-14-60
TL Number from the TL Form:
Sample Submitted By Organization: Blackburn Consulting
Sample Organization Contact: (916) 375-8706
Type of Sample: Verification
Type of Material: Asphalt Rubber Binder
Sample Taken Date: 08/14/2024
Date that the sample was received by the laboratory/organization performing the testing: 08/30/2024
The quantity of what the sample constitutes: 1 Can
A brief description of the sample: 3/4" RHMA-G-SP, PG 64-16
From where was the sample collected: Source
Laboratory sample identification: 4147
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Teichert Hallwood
Asphalt modifier supplier: PNW
Performance Grade: PG 64-16
Lot number: 3
Sublot number: 17
Asphalt Rubber Binder Mix Number:
