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: 2024-06-04-48
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:
HMA
FOR USE IN:
SAMPLE FROM:
Plant
DEPTH:
LOCATION OF SOURCE:
91-37-0036
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-37-0036
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
06/04/2024
BY:
Ben Smith
TITLE:
DIST, CO, RTE, PM:
11-SD-52-5.1/9.0
CONT. NO.:
DEA: 11430254
FED. NO.:
LIMITS:
SAN DIEGO COUNTY IN SAN DIEGO FROM 0.4 MILE WEST O
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
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