Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 995087 DEA: 051P5904 EFIS: 0522000086
QA Service Level: 1
DIST-CO-RTE-PM: 05-SCR-1-0.0/5.0
Work Description: Cold plane, RHMA-G
Location Description: Watsonville area, County line to Scenic pullout
Contractor Name: A. TEICHERT & SON, INC. DBA TEICHERT CONSTRUCTION
Contractor Address: 3500 American River Dr, Sacramento CA 95864
Resident Engineer: Tyler Lavering Structure Rep.: Unknown
DIME Sample ID: 2023-09-06-17
TL Number from the TL Form:
Sample Submitted By Organization: CT D05 - Santa Cruz Field Laboratory
Sample Organization Contact:
Type of Sample: Quality Assurance
Type of Material: Asphalt Rubber Binder
Sample Taken Date: 09/06/2023
Date that the sample was received by the laboratory/organization performing the testing: 09/06/2023
The quantity of what the sample constitutes: 2-1 Qt Cans
A brief description of the sample: ARB pg 64-16
From where was the sample collected: Source
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: National Blending Company
Asphalt modifier supplier: San Joaquin Refining Co Inc
Performance Grade: PG 64-16
Lot number: 1
Sublot number: 2
Asphalt Rubber Binder Mix Number: 23_1354