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: 2022-07-20-39
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:
EMULSION / LOAD 17 / 2ND BOTTLE DOES NOT CONSTITUTE SPLIT SAMPLE AND IS NOT TESTED
FOR USE IN:
SAMPLE FROM:
Job Site
DEPTH:
LOCATION OF SOURCE:
WESTERN EMULSIONS
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
WESTERN EMULSIONS
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/20/2022
BY:
SEE TL101
TITLE:
DIST, CO, RTE, PM:
05-SLO-166-16.0/21.0
CONT. NO.:
DEA: 051N7004
FED. NO.:
LIMITS:
SAN LUIS OBISPO COUNTY ABOUT 8 MILES EAST OF SANTA
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
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