Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215682 DEA: 031H1904 EFIS: 0316000065
QA Service Level: 1
DIST-CO-RTE-PM: 03-SAC-80,244-M9.6/12.9,0.0/T0.8
Work Description: COLD PLANE AC PAVEMENT, PLACE RHMA AND INDIVIDUAL SLAB REPLACEMENT.
Location Description: SACRAMENTO COUNTY IN AND NEAR SACRAMENTO ON ROUTE 80 FROM 0.2 MILE EAST OF LONGVIEW DRIVE OVERCROSSING TO 0.4 MILE EAST OF MADISON AVENUE OVERCROSSING AND ON ROUTE 244 FROM 0.3 MILE NORTH OF AUBURN BOULEVARD TO CONNECTOR TO ROUTE 80
Contractor Name: A. Teichert and Sons, Inc. DBA Teichert Construction
Contractor Address: 400 Sunrise Blvd., Roseville, CA 95661
Resident Engineer: Deyaedden Elghassein Structure Rep.: Unknown
DIME Sample ID: 2022-10-14-8
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: Asphaltic Emulsion
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 Oil Jug
A brief description of the sample: Tack Coat
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Teichert Perkins
