Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 214469 DEA: 030H08U4 EFIS: 0319000029
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-50-L0.2/R6.1
Work Description: Sac 50 Design Build PLEASE NOTE THAT DESIGN BUILDER MUST PERFORM QUALITY VALIDATION TESTING IN ACCORDANCE WITH THE MATERIAL CONTROL SCHEDULE (MCS) FOR ITEMS SUCH AS STRANDS, HS BOLTS, ELASTOMERIC BEARING PADS, JOINT SEALANTS, COUPLERS & WELDED HOOPS, ETC
Location Description: FROM 0.1 MILE EAST OF I-5 TO 0.8 MILE EAST OF WATT AVE
Contractor Name: FLATIRON WEST INC
Contractor Address: 2100 Goodyear Rd., Benicia, CA 94510
Resident Engineer: Jim Rogers Structure Rep.: Daniel Eggers
DIME Sample ID: 2022-10-14-7
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: 10/14/2022
Date that the sample was received by the laboratory/organization performing the testing: 10/14/2022
The quantity of what the sample constitutes: 1 jug
A brief description of the sample: 3/4" HMA-SP Oil
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Teichert Perkins
Performance Grade: PG 64-16
Modified: No
Lot number: 3
Sublot number: 1
Tank number:
Time of sample:
HMA Supplier: Teichert Perkins
Certified Asphalt Supplier: Pacific Northwest Oil - Stockton CA
Multigrade: No
Multigrade Type:
Asphalt Binder Mix Number:
