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: 2023-06-29-19
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:
1/2" RHMA-G
FOR USE IN:
SAMPLE FROM:
Supplier
DEPTH:
LOCATION OF SOURCE:
AAA-Corona
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
AAA-Corona
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
06/29/2023
BY:
Kreetha Mekchai
TITLE:
Plant Inspector (6267645399)
DIST, CO, RTE, PM:
12-ORA-405,73,405,605-9.3/24.3
CONT. NO.:
DEA: 120H1004
FED. NO.:
LIMITS:
Orange and Los Angeles Counties: 12-ORA-405 PM 9.3
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
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