Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994636 DEA: 022J9604 EFIS: 0221000153
QA Service Level: 1
DIST-CO-RTE-PM: 02-SIS-5-VAR
Work Description: PLACE POLYESTER CONCRETE OVERLAY, HMA (TYPE A), & REPLACE JOINT SEALS.
Location Description: SISKIYOU COUNTY AT VARIOUS LOCATIONS FROM OAK STREET UNDERCROSSING TO KLAMATH RIVER BRIDGE AND SEPARATION BRIDGE NO. 02-0134R
Contractor Name: DEES BURKE ENGINEERING CONSTRUCTORS, LLC
Contractor Address: 207 W State Street, Ontario, CA 91762
Resident Engineer: Nicole Mallory Structure Rep.: Carlos Paz
DIME Sample ID: 2024-08-01-10
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - FFS - Skid Testing
Sample Organization Contact: (916) 227-7287
Type of Sample: Acceptance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 08/01/2024
Date that the sample was received by the laboratory/organization performing the testing: 08/01/2024
The quantity of what the sample constitutes: POLYESTER
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: 2024-08-01-10-1
Test Method: CTM 342-August 2012: Method of Test for Surface Skid Resistance with the California Portable Skid Tester (Skid)
Verified Date: 08/02/2024
Date Tested: 08/02/2024
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: N MT. SHASTA SEPARATION-02-0091K
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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0.40
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