Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994876 DEA: 101N7704 EFIS: 1022000025
QA Service Level: 1
DIST-CO-RTE-PM: 10-SJ-5-0.6
Work Description: PLACE POLYESTER CONCRETE OVERLAY ON BRIDGE AND REPLACE JOINT SEALS.
Location Description: SAN JOAQUIN COUNTY NEAR TRACY AT ROUTE 5/580 SEPARATION
Contractor Name: PETERSON-CHASE GENERAL ENGINEERING CONSTRUCTION INC.
Contractor Address: 16351 Construction cir., Irvine CA 95606
Resident Engineer: Ranbir Bhullar Structure Rep.: Unknown
DIME Sample ID: 2024-05-18-1
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - FFS - Skid Testing
Sample Organization Contact: (916) 227-7287
Type of Sample: Quality Assurance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 05/18/2024
Date that the sample was received by the laboratory/organization performing the testing: 05/21/2024
The quantity of what the sample constitutes: skid testing
A brief description of the sample: Portable Skid Test
From where was the sample collected: Job Site
Laboratory sample identification:
Structure unique identifier:
Structure name: 5/580 Sep
The fabricator/manufacturer/facility name: Job Site
Pavement Surface Type: Polyester Concrete
Type of Traffic Control Provided: N/A
DIST-CO-RTE:
Direction of Travel: East
Post Mile:
Lanes to be Tested: Lane #1
Station:
