Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994910 DEA: 061A1104 EFIS: 0621000175
QA Service Level: 1
DIST-CO-RTE-PM: 06-FRE-99-
Work Description:
Location Description:
Contractor Name: PETERSON-CHASE GENERAL ENGINEERING CONSTRUCTION INC.
Contractor Address: 16351 Construction Cir W, Irvine, CA 9206
Resident Engineer: Ryan Wilson Structure Rep.: Unknown
DIME Sample ID: 2023-09-14-42
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: 09/14/2023
Date that the sample was received by the laboratory/organization performing the testing: 09/14/2023
The quantity of what the sample constitutes: BRIDGE DECK
A brief description of the sample: polyester
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: job site
DIME Test ID: 2023-09-14-42-1
Test Method: CTM 342-August 2012: Method of Test for Surface Skid Resistance with the California Portable Skid Tester (Skid)
Verified Date: 09/20/2023
Date Tested: 09/14/2023
Submitted By Organization: CT HQ - FFS - Skid Testing
Organization Address: ,
Organization City:
Organization State:
Organization Zipcode:
Organization Email: steven.seifert@dot.ca.gov
Organization Phone: (916) 227-8588
General Comments for this Test: 99SB OFF RAMP/99 SEPERATION/42-0218K
Test Result Compliance: complies
Additional Comments When Verified:
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Pavement or Bridge Deck?
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Bridge Deck
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Average Coefficient of Friction
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0.45
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