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: 2021-10-08-12
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" HMA-A-SP R15, NO LAS
FOR USE IN:
Asphalt Paving
SAMPLE FROM:
Belt Cut at All American Corona Plant
DEPTH:
LOCATION OF SOURCE:
91-33-0005
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-33-0005
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
10/08/2021
BY:
Zaid Abdelkhaliq
TITLE:
DIST, CO, RTE, PM:
07-LA-10-R12.4/14.9
CONT. NO.:
DEA: 07332604
FED. NO.:
LIMITS:
THE COUNTY AND CITY OF LOS ANGELES FROM 0.1 MILE E
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
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