Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214492 DEA: 033F5404 EFIS: 0313000136
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-99,160-4.5/5.7,R44.5
Work Description: FURNISH PRECAST PRESTRESSED CONCRETE SLAB & PLACE STRUCTURAL CONCRETE.
Location Description: SACRAMENTO COUNTY NEAR GALT ON ROUTE 99 FROM NORTH OF MINGO ROAD TO SOUTH OF ARNO ROAD OVERCROSSING AND IN SACRAMENTO ON ROUTE 160 AT AMERICAN RIVER BRIDGE
Contractor Name: BROSAMER & WALL, INC.
Contractor Address: 5000 Marsh Drive, Suite 300, Conord, CA 94520
Resident Engineer: Mohssen Ghassemi Structure Rep.: Chris Quon
DIME Sample ID: 2021-03-05-24
TL Number from the TL Form: C 849135
Sample Submitted By Organization: CT D03 - Olivehurst Northern Regional Laboratory
Sample Organization Contact: (530) 741-4238
Type of Sample: Verification
Type of Material: Asphalt Binder
Sample Taken Date: 03/05/2021
Date that the sample was received by the laboratory/organization performing the testing: 03/08/2021
The quantity of what the sample constitutes: JMF Verification
A brief description of the sample: PG-64-16
From where was the sample collected: Manufacturer
Laboratory sample identification: JMF21-009
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Teichert Perkins - Continuous Plant Dreyer Drum
Performance Grade: PG 64-16
Modified: Yes
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Valero Marketing & Supply - Benicia CA
Multigrade: Yes
Multigrade Type:
Asphalt Binder Mix Number:
