Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215626 DEA: 032G1504 EFIS: 0320000234
QA Service Level: 1
DIST-CO-RTE-PM: 03-PLA-193-3.0/10.1
Work Description: COLD PLANE AC PAVEMENT & RHMA OVERLAY.
Location Description: PLACER COUNTY NEAR LINCOLN FROM SIERRA COLLEGE BOULEVARD TO OPHIR ROAD
Contractor Name: A. TEICHERT & SON, INC. DBA TEICHERT CONSTRUCTION
Contractor Address: 265 VAL DERVIN PARKWAY, STOCKTON, CA 95201
Resident Engineer: Martin Clark Structure Rep.: Unknown
DIME Sample ID: 2021-06-04-20
TL Number from the TL Form:
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: 06/04/2021
Date that the sample was received by the laboratory/organization performing the testing: 06/22/2021
The quantity of what the sample constitutes: 3 cans
A brief description of the sample: PG64-16 Asphalt Binder
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Teichart-Hallwood Drum Plant
Performance Grade: PG 64-16
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Marathon Petroleum Co. LP - Elk Grove CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
