Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993480 DEA: 032G3904 EFIS: 0321000120
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-51-4.7/5.2,5.9/8.8
Work Description: COLD PLANE AC PAVEMENT, PLACE HMA AND REPLACE CONCRETE SLABS.
Location Description: SACRAMENTO COUNTY IN AND NEAR SACRAMENTO FROM EL CAMINO AVENUE OVERCROSSING TO 0.4 MILE SOUTH OF MARCONI AVENUE OVERCROSSING AND FROM 0.4 MILE NORTH OF MARCONI AVENUE OVERCROSSING TO ROUTE 80, 51/244 SEPARATION
Contractor Name: A. TEICHERT & SON INC. DBA TEICHERT CONSTRUCTION
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Unknown
DIME Sample ID: 2022-06-28-15
TL Number from the TL Form:
Sample Submitted By Organization: Blackburn Consulting
Sample Organization Contact: (916) 375-8706
Type of Sample: Quality Assurance
Type of Material: Asphalt Binder
Sample Taken Date: 06/28/2022
Date that the sample was received by the laboratory/organization performing the testing: 06/28/2022
The quantity of what the sample constitutes: 750 Tons
A brief description of the sample: SS-1H 1jug emulsion
From where was the sample collected: Distributor
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Pacific Northwest Oil
Performance Grade: PG 64-16
Modified: No
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Pacific Northwest Oil - Stockton CA
Multigrade: Yes
Multigrade Type:
Asphalt Binder Mix Number:
