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: 2021-08-17-2
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" x 18" anchor bolt with 4" hook
FOR USE IN:
SAMPLE FROM:
Manufacturer
DEPTH:
LOCATION OF SOURCE:
A and M Nut and Bolt
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
A and M Nut and Bolt
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
08/17/2021
BY:
Steve Hall
TITLE:
CT METS QA INSPECTOR (6466327821)
DIST, CO, RTE, PM:
59---
CONT. NO.:
DEA: SMTL-STOCK
FED. NO.:
LIMITS:
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
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