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: 2020-07-07-5
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:
JMF 3/4" HMA-A-SP 0.25% EVO
FOR USE IN:
Asphalt Paving
SAMPLE FROM:
Belt Cut at Vulcan Bullead City Plant
DEPTH:
LOCATION OF SOURCE:
CM2056
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
CM2056
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/07/2020
BY:
Austin Beeler
TITLE:
DIST, CO, RTE, PM:
08-SBD-95-64.5/80.5
CONT. NO.:
DEA: 081F1324
FED. NO.:
LIMITS:
SAN BERNARDINO COUNTY ON ROUTE 95 FROM 0.5 MILE NO
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
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