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: 2020-08-12-19
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-A R24 PG64-28M (0.50% LAS)
FOR USE IN:
SAMPLE FROM:
Manufacturer
DEPTH:
LOCATION OF SOURCE:
CCA-Coachella
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
CCA-Coachella
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
08/12/2020
BY:
Kevin Oluoha
TITLE:
DIST, CO, RTE, PM:
08-RIV-10-6.7/R25.1
CONT. NO.:
DEA: 081C38U4
FED. NO.:
LIMITS:
ROUTE 10/60 SEPARATION IN BEAUMONT TO ROUTE 10/111
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
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