Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001123 DEA: 051H4704 EFIS: 0516000078
QA Service Level: 1
DIST-CO-RTE-PM: 05-SCR-9-9-13.6,15.5
Work Description: REPLACE BRIDGES AND INSTALL MGS.
Location Description: SANTA CRUZ COUNTY NEAR BOULDER CREEK AT SAN LORENZO RIVER BRIDGE AND AT KINGS CREEK BRIDGE
Contractor Name: GORDON N. BALL, INC.
Contractor Address: Unknown
Resident Engineer: Ian Nguyen Structure Rep.: Jarred Burrows
DIME Sample ID: 2026-08-28-9
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - QASI Bay Area Field Office
Sample Organization Contact: (916) 284-6784
Type of Sample: Acceptance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 08/28/2026
Date that the sample was received by the laboratory/organization performing the testing:
The quantity of what the sample constitutes: BRIDGE DECK
A brief description of the sample: Skid Testing Request
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier: 36-0054
Structure name: Kings Creek Bridge
The fabricator/manufacturer/facility name: Gordon Ball Construction
Pavement Surface Type: PCC (Portland Cement Concrete)
Type of Traffic Control Provided: Stationary Lane Closure
DIST-CO-RTE: 5-SCr-009
Direction of Travel:
Post Mile: 15.50
Lanes to be Tested:
Station:
