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: 2022-04-21-15
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:
A set of 2 JPCP concrete beam test specimens
FOR USE IN:
SAMPLE FROM:
Concrete from wheelbarrow
DEPTH:
LOCATION OF SOURCE:
SECURITY PAVING PORTABLE PLANT- LA MIRADA
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
SECURITY PAVING PORTABLE PLANT- LA MIRADA
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
04/21/2022
BY:
Edmond Jabbour
TITLE:
Field Materials Tester (19092398226)
DIST, CO, RTE, PM:
07-LA,ORA-5-0.0/1.5, 44.3/44.4
CONT. NO.:
DEA: 072159U4
FED. NO.:
LIMITS:
LOS ANGELES AND ORANGE COUNTIES IN BUENA PARK, LA
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
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