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: 2025-09-29-1
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:
HDG 2.25" x 75.5" F1554 G55 Anchor bolt assembly with 2.25"x4.5" Heavy Hex Nut 2H/DH ASTM A563, 2.25" F436 hardened washer,
FOR USE IN:
SAMPLE FROM:
Source
DEPTH:
LOCATION OF SOURCE:
Halo Structural Products
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Halo Structural Products
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
09/29/2025
BY:
Kent Allen
TITLE:
DIST, CO, RTE, PM:
12-ORA-55-0.2/R17.8
CONT. NO.:
DEA: 120R32U4
FED. NO.:
LIMITS:
ORANGE COUNTY FROM 0.1 MILE SOUTH OF ROUTE 55/1 SE
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
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