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: 2016-10-12-18
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:
3/8 PCC Aggregates
FOR USE IN:
Unknown
SAMPLE FROM:
Stockpile @ Plant

DEPTH:
LOCATION OF SOURCE:
91-49-0032::MARK WEST QUARRY

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-49-0032::MARK WEST QUARRY
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
10/12/2016
BY: Plant Personnel
TITLE:
Unknown (Unknown)
DIST, CO, RTE, PM:
04-SON-12-9.6
CONT. NO.: DEA: 041A2904
FED. NO.:
LIMITS:
SONOMA COUNTY NEAR THE CITY OF SEBASTOPOL AT LAGUN
RECIPIENT(S): (to be selected by data publishing engineer)
CONTRACTOR:

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