Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 215620 DEA: 01436404 EFIS: 0100000193
QA Service Level: 1
DIST-CO-RTE-PM: 01-DN-101-35.8/36.5
Work Description: Dr. Fine Bridge Replacement
Location Description: DR. FINE BRIDGE REPLACEMENT FROM LAKE EARL DR TO S FRED D. HAIGHT DR ON HWY 101 ACROSS SMITH RIVER.
Contractor Name: MCM Construction
Contractor Address: PO Box 620, North Highlands, Ca 95660
Resident Engineer: Clayton Malmberg Structure Rep.: Brian Cinkutis
DIME Sample ID: 2025-12-10-2
TL Number from the TL Form:
Sample Submitted By Organization: CT D01 - Crescent City Field Laboratory
Sample Organization Contact: (707) 496-5581
Type of Sample: Acceptance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 12/10/2025
Date that the sample was received by the laboratory/organization performing the testing: 12/10/2025
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:
Structure name:
The fabricator/manufacturer/facility name: ABC Paving Co.
Pavement Surface Type: PCC (Portland Cement Concrete)
Type of Traffic Control Provided: Behind K-Rail/Barrier
DIST-CO-RTE: 01-DN-101
Direction of Travel: North
Post Mile: 35.80
Lanes to be Tested: Shoulder,Lane #1,Lane #2
Station:
