Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 993907 DEA: 061E2004 EFIS: 0621000225
QA Service Level: 1
DIST-CO-RTE-PM: 06-MAD-99,152-24.8,7.3
Work Description: REPAIR BRIDGE DECK AND PLACE POLYESTER CONCRETE OVERLAY.
Location Description: MADERA COUNTY NEAR CHOWCHILLA ON ROUTE 99 AT BERENDA SLOUGH BRIDGE AND ON ROUTE 152 AT ASH SLOUGH BRIDGE
Contractor Name: VELARDE CONCRETE CONSTRUCTION
Contractor Address: 523 SOUTH BRAND BOULEVARD, SAN FERNANDO, CA 91340
Resident Engineer: Victor Shaw Structure Rep.: Unknown
DIME Sample ID: 2023-06-11-10
TL Number from the TL Form:
Sample Submitted By Organization: CT HQ - FFS - Skid Testing
Sample Organization Contact: (916) 227-7287
Type of Sample: Department Acceptance
Type of Material: Roadway/Bridge Surface
Sample Taken Date: 06/11/2023
Date that the sample was received by the laboratory/organization performing the testing: 06/11/2023
The quantity of what the sample constitutes: poly
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: 2023-06-11-10-1
Test Method: CTM 342-August 2012: Method of Test for Surface Skid Resistance with the California Portable Skid Tester (Skid)
Verified Date: 06/13/2023
Date Tested: 06/11/2023
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: BRIDE DECK TESTED ALSO A TEST AND VISUAL INSPECTION ON APPROACH SLAB AND ALL LOOKED UNIFORMED. DEPARTURE SLAB WAS NOT DONE AS THEY DID NOT FINISH LAYING DOWN MATERIAL
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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