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: 2021-09-12-3
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:
Asphalt Rubber Binder
FOR USE IN:
SAMPLE FROM:
Job Site
DEPTH:
LOCATION OF SOURCE:
George Reed - Clements Plant
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
George Reed - Clements Plant
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
09/12/2021
BY:
na na
TITLE:
GRI QC ()
DIST, CO, RTE, PM:
10-SJ-4-5.4/13.4
CONT. NO.:
DEA: 101L2304
FED. NO.:
LIMITS:
SAN JOAQUIN COUNTY NEAR STOCKTON FROM 1 MILE EAST
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
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