Sample Identification Card TL-0101
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STATE OF CALIFORNIA ● DEPARTMENT OF TRANSPORTATION
SAMPLE IDENTIFICATION CARD
TL-0101 (REV. 02/17)
DIME Sample ID: 2024-09-05-77
FIELD NO.
DIST LAB NO.
LOT NO.
P.O. OR REQ. NO.
TEST TYPE:
SHIPMENT NO.
AUTHORIZATION NO.
SAMPLE SENT TO:
HDQRS. LAB
BRANCH LAB
DIST. LAB
TRANS. LAB
SAMPLE OF:
3/4" HMA 25%Rap Aggs
FOR USE IN:
SAMPLE FROM:
Sampled from belt stream at the plant
DEPTH:
LOCATION OF SOURCE:
Vulcan Vallejo
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Vulcan Vallejo
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
09/05/2024
BY:
Jacob Vega
TITLE:
Lab Technician ()
DIST, CO, RTE, PM:
04-NAP-221-0.2/1.7
CONT. NO.:
DEA: 042Y5004
FED. NO.:
LIMITS:
NAPA COUNTY IN AND NEAR NAPA FROM 0.2 MILE NORTH O
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
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