Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994088 DEA: 01434844 EFIS: 0117000133
QA Service Level: 1
DIST-CO-RTE-PM: 01-MEN-1-51.3/52.1
Work Description: Jack Peters Creek Bridge
Location Description: MENDOCINO COUNTY AT MENDOCINO FROM LARKIN ROAD TO 0.2 MILE SOUTH OF SURFWOOD ESTATES ROAD
Contractor Name: MCCULLOUGH CONSTRUCTION INC
Contractor Address: 57 Alder Grove Road, Arcata, CA 95521
Resident Engineer: Mojtaba Mosallai Structure Rep.: Kari Forbes
DIME Sample ID: 2025-09-16-20
TL Number from the TL Form:
Sample Submitted By Organization: CT SC - 3667 - Redwood Valley/Fort Bragg
Sample Organization Contact: (707) 498-1012
Type of Sample: Acceptance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 09/16/2025
Date that the sample was received by the laboratory/organization performing the testing: 09/16/2025
The quantity of what the sample constitutes: Multiple Lanes
A brief description of the sample: Skid Testing Request
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 10-0150
Structure name: Jack Peters Creek Bridge
The fabricator/manufacturer/facility name: Dees Burke
DIME Test ID: 2025-09-16-20-1
Test Method: CTM 342-August 2012: Method of Test for Surface Skid Resistance with the California Portable Skid Tester (Skid)
Verified Date: 09/23/2025
Date Tested: 09/22/2025
Submitted By Organization: CT HQ - FFS - Skid Testing
Organization Address: ,
Organization City:
Organization State:
Organization Zipcode:
Organization Email: steven.seifert@dot.ca.gov
Organization Phone: (916) 227-8588
General Comments for this Test: JACK PETERS CREEK BRIDGE
Test Result Compliance: complies
Additional Comments When Verified:
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Pavement or Bridge Deck?
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Bridge Deck
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Average Coefficient of Friction
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0.39
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