Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215062 DEA: 030F2904 EFIS: 0314000101
QA Service Level: 1
DIST-CO-RTE-PM: 03-BUT-99-14.9/15.7
Work Description: CONSTRUCT BRIDGE AND ROADWAY; & REMOVE BRIDGE.
Location Description: BUTTE COUNTY ABOUT 10 MILES NORTH OF GRIDLEY FROM 0.3 MILE SOUTH TO 0.5 MILE NORTH OF NELSON AVENUE
Contractor Name: A. TEICHERT & SON, INC. DBA TEICHERT CONSTRUCTION
Contractor Address: 400 Sunrise Ave Ste 300,, Roseville, CA 95661
Resident Engineer: Daniel Rechs Structure Rep.: James Ralston
DIME Sample ID: 2021-04-01-35
TL Number from the TL Form: C706327
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: 04/01/2021
Date that the sample was received by the laboratory/organization performing the testing: 04/01/2021
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:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Teichert - Hallwood Plant
Performance Grade: PG 64-16
Modified: No
Lot number:
Sublot number:
Tank number: Unknown
Time of sample: Unknown
HMA Supplier: Teichert - Hallwood Plant
Certified Asphalt Supplier: Valero Marketing & Supply - Benicia CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
