Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993699 DEA: 032G3604 EFIS: 0321000117
QA Service Level: 1
DIST-CO-RTE-PM: 03-GLE-45-13.0/17.2
Work Description: ROADWAY EXCAVATION, HMA (TYPE A) AND CLASS 2 AB.
Location Description: GLENN COUNTY NEAR HAMILTON CITY FROM 0.5 MILE NORTH OF BAYLISS BLUE GUM ROAD TO ROAD 29
Contractor Name: A. TEICHERT & SON, INC. DBA TEICHERT CONSTRUCTION
Contractor Address: 4401 Duluth Ave, Rocklin, CA 95765
Resident Engineer: Michael Mattson Structure Rep.: Unknown
DIME Sample ID: 2022-10-19-60
TL Number from the TL Form: 779503
Sample Submitted By Organization: CT HQ - Sacramento Asphalt Binder Laboratory
Sample Organization Contact: (916) 227-7302
Type of Sample: Department Acceptance
Type of Material: Asphaltic Emulsion
Sample Taken Date: 10/19/2022
Date that the sample was received by the laboratory/organization performing the testing: 11/01/2022
The quantity of what the sample constitutes: 1 qt jug
A brief description of the sample: SS-1H 1jug emulsion
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: teichart