Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1000704 DEA: 031J8001 EFIS: 0321000071 Permit Numbers: 0324NOP0141
QA Service Level: 2
DIST-CO-RTE-PM: 03---
Work Description:
Location Description:
Contractor Name: Unknown
Contractor Address: Unknown
Resident Engineer: Unknown Structure Rep.: Ken Haas
DIME Sample ID: 2026-06-17-13
TL Number from the TL Form: CT HQ - FFS - Skid Testing
Sample Submitted By Organization: CT SC - 3665 - Rocklin
Sample Organization Contact: (530) 320-6475
Type of Sample: Production Start-Up
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 06/17/2026
Date that the sample was received by the laboratory/organization performing the testing: 06/17/2026
The quantity of what the sample constitutes: contractor's trail pass for skid testing
A brief description of the sample: Skid Testing Request
From where was the sample collected: Job Site
Laboratory sample identification: CT HQ - FFS - Skid Testing
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Dees Burke Engineering Contractors
Pavement Surface Type: Polyester Concrete
Type of Traffic Control Provided: Stationary Lane Closure
DIST-CO-RTE:
Direction of Travel:
Post Mile:
Lanes to be Tested: Shoulder
Station:
