Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994550 DEA: 032G5304 EFIS: 0321000236
QA Service Level: 1
DIST-CO-RTE-PM: 03-PLA,SAC-50,65,80-VAR
Work Description: REPAIR UNSOUND CONC, PLACE POLYESTER CONC OVERLAY AND INJECT EPOXY.
Location Description: PLACER AND SACRAMENTO COUNTIES AT VARIOUS LOCATIONS
Contractor Name: DEES BURKE ENGINEERING CONSTRUCTORS, LLC
Contractor Address: 3221 Rippey Rd, Loomis, CA 95650
Resident Engineer: Justin Kunert Structure Rep.: Hyonsohk Ohm
DIME Sample ID: 2023-07-20-17
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - FFS - Skid Testing
Sample Organization Contact: (916) 227-7287
Type of Sample: Department Acceptance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 07/20/2023
Date that the sample was received by the laboratory/organization performing the testing: 07/20/2023
The quantity of what the sample constitutes: Skid Testing
A brief description of the sample: Towed Trailer
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Job Site
