Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993193 DEA: 031H18U4 EFIS: 0321000106
QA Service Level: 1
DIST-CO-RTE-PM: 03-NEV-80-13.0/16.5
Work Description: ROADWAY EXCAVATION, JPCP AND FURNISH POLYESTER CONCRETE OVERLAY.
Location Description: NEVADA COUNTY IN AND NEAR TRUCKEE FROM 0.2 MILE WEST OF DONNER PARK OVERCROSSING TO ROUTE 89/267 SEPARATION
Contractor Name: A. TEICHERT & SON, INC. DBA TEICHERT CONSTRUCTION
Contractor Address: Unknown
Resident Engineer: Randy Stellhorn Structure Rep.: Carl Anderson
DIME Sample ID: 2022-10-05-48
TL Number from the TL Form:
Sample Submitted By Organization: Blackburn Consulting
Sample Organization Contact: (916) 375-8706
Type of Sample: Quality Control
Type of Material: Asphalt Binder
Sample Taken Date: 10/05/2022
Date that the sample was received by the laboratory/organization performing the testing: 10/05/2022
The quantity of what the sample constitutes: 3 Oil Cans
A brief description of the sample: 3/4" HMA Oil
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Martis Valley
Performance Grade: PG 64-28
Modified: No
Lot number: 1
Sublot number: 13
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier: Pacific Northwest Oil - Stockton CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
