Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 212914 DEA: 031E0604 EFIS: 0312000068
QA Service Level: 1
DIST-CO-RTE-PM: 03-YUB-70-15.5/16.5
Work Description: SIMMERLY SLOUGH BRIDGE REPLACEMENT BR 16-0019 WITH BR 16-0055.
Location Description: NEAR MARYSVILLE, FROM 0.1 MILE NORTH OF BINNEY JUNCTION UNDERPASS TO 0.3 MILE NORTH OF LAURELLEN ROAD, AT SIMMERLY SLOUGH BRIDGE BR 16-0019.
Contractor Name: MCM Construction
Contractor Address: PO Box 620, North Highlands, Ca 95660
Resident Engineer: Manoharan Selvendran Structure Rep.: Travis Christie
DIME Sample ID: 2021-04-28-30
TL Number from the TL Form: C741863
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: 04/28/2021
Date that the sample was received by the laboratory/organization performing the testing: 04/28/2021
The quantity of what the sample constitutes: 1 CAN
A brief description of the sample: PG 64-16
From where was the sample collected: Manufacturer
Laboratory sample identification: JMF21-024
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:
Time of sample:
HMA Supplier: Teichert-Hallwood Plant
Certified Asphalt Supplier: Pacific Northwest Oil - Stockton CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
