Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000004 DEA: 033H5604 EFIS: 0318000014
QA Service Level: 1
DIST-CO-RTE-PM: 03-PLA,NEV-20,80-VAR
Work Description: STRUCTURAL CONC, BAR REINFORCING STEEL, BRIDGE REMOVAL, HMA, AND JPCP.
Location Description: PLACER AND NEVADA COUNTIES NEAR CISCO GROVE ON ROUTE 80 FROM 0.4 MILE WEST OF LAKE VALLEY OVERCROSSING TO 0.9 MILE EAST OF YUBA PASS SEPARATION AND OVERHEAD AND ON ROUTE 20 AT YUBA PASS SEPARATION AND OVERHEAD
Contractor Name: FLATIRON WEST INC.
Contractor Address: 1200 Concord Ave Suite 465, Concord, CA 94520
Resident Engineer: Tad Sampson Structure Rep.: James 'Jimmer' Ross
DIME Sample ID: 2025-12-08-3
TL Number from the TL Form:
Sample Submitted By Organization: CT D03 - Rocklin Construction Field Office
Sample Organization Contact: 530-330-2727
Type of Sample: Acceptance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 12/08/2025
Date that the sample was received by the laboratory/organization performing the testing:
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: 17-0107R
Structure name: Yuba Pass Separation and OH Bridge
The fabricator/manufacturer/facility name: Flatiron
Pavement Surface Type: PCC (Portland Cement Concrete)
Type of Traffic Control Provided: Behind K-Rail/Barrier
DIST-CO-RTE: 03-Nev-80
Direction of Travel: East
Post Mile:
Lanes to be Tested: Lane #1,Lane #2
Station: 59.5
