Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993183 DEA: 031H2704 EFIS: 0316000082
QA Service Level: 1
DIST-CO-RTE-PM: 03-YUB-70-R11.2/13.5
Work Description: UPGRADE BRIDGE RAILS & CONSTRUCT CONCRETE MEDIAN BARRIER.
Location Description: YUBA COUNTY NEAR LINDA AND MARYSVILLE FROM 2.4 MILES SOUTH OF FEATHER RIVER BOULEVARD UNDERCROSSING TO THE YUBA RIVER BRIDGE AND OVERHEAD
Contractor Name: BRIDGEWAY CIVIL CONSTRUCTORS, INC.
Contractor Address: 4950 Allison Parkway, # A, Vacaville, CA 95688
Resident Engineer: Selvendran Manoharan Structure Rep.: Brent Bullard
DIME Sample ID: 2022-01-21-49
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: 01/21/2022
Date that the sample was received by the laboratory/organization performing the testing: 02/10/2022
The quantity of what the sample constitutes: 12 boxes of HMA, 2 cans of binder
A brief description of the sample: pg 64-16 PNW
From where was the sample collected: Supplier
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: PNW
Performance Grade: PG 64-16
Modified:
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Pacific Northwest Oil - Stockton CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
