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:2017-03-06-10
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 gallon can
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
reichhold azusa

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
reichhold azusa
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
03/06/2017
BY: Chris Nunes
TITLE:
Unknown (Unknown)
DIST, CO, RTE, PM:
04-SF-280-R4.8/R6.2
CONT. NO.: DEA: 042A4904
FED. NO.:
LIMITS:
THE CITY AND COUNTY OF SAN FRANCISCO AT VARIOUS LO
RECIPIENT(S):
CONTRACTOR:
Myers and Sons / RL Wadsworth JV

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