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: 2021-06-03-14
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:
PSUE 3/4" RHMA-G-SP 0.5% LAS
FOR USE IN:
Asphalt Paving
SAMPLE FROM:
Belt Cut at Matich Cabazon Plant
DEPTH:
LOCATION OF SOURCE:
91-33-0008, 91-36-0040
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-33-0008, 91-36-0040
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
06/03/2021
BY:
Kevin Oluoha
TITLE:
DIST, CO, RTE, PM:
08-RIV,SBD-62-R6.7/9.2,0.0/15.1,29.3/33.6
CONT. NO.:
DEA: 081E8404
FED. NO.:
LIMITS:
IN RIVERSIDE AND SAN BERNARDINO COUNTIES IN AND NE
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
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