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
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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