Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1002184 DEA: 080N0304 EFIS: 0824000176
QA Service Level: 1
DIST-CO-RTE-PM: 08-SBD-15,40-VAR
Work Description: Polyester concrete overlay and HMA asphalt (Type A).
Location Description: CONSTRUCTION ON STATE HIGHWAY IN SAN BERNARDINO COUNTY AT VARIOUS LOCATIONS.
Contractor Name: VELARDE CONCRETE CONSTRUCTION
Contractor Address: 523 S. BRAND BLVD, SAN FERNANDO CA 91340
Resident Engineer: Pham Thanh Structure Rep.: Jegbefume Adodo
DIME Sample ID: 2026-08-27-7
TL Number from the TL Form:
Sample Submitted By Organization: Caltrans IA
Sample Organization Contact: (916) 240-3821
Type of Sample: Acceptance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 08/27/2026
Date that the sample was received by the laboratory/organization performing the testing: 08/27/2026
The quantity of what the sample constitutes: Trial Slab and 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: Ghost Town Road UC
The fabricator/manufacturer/facility name: Kwik-Bond
Pavement Surface Type: Polyester Concrete
Type of Traffic Control Provided: Stationary Lane Closure
DIST-CO-RTE: 08-SBd-15
Direction of Travel: North
Post Mile: 81.83
Lanes to be Tested: Shoulder
Station:
