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: 2017-03-23-5
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:
A325 HDG
FOR USE IN:
SAMPLE FROM:
Distributor
DEPTH:
LOCATION OF SOURCE:
Universal Industrial Sales
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Universal Industrial Sales
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
03/23/2017
BY:
Scott Leavitt
TITLE:
Unknown (Unknown)
DIST, CO, RTE, PM:
10-TUO-120-R19.5/R20.0
CONT. NO.:
DEA: 100L9704
FED. NO.:
LIMITS:
IN TUOLUMNE COUNTY ON STATE ROUTE 120 FROM 7.6 MIL
RECIPIENT(S):
sleavitt@altavistasolutions.com;gino.del.chiaro@dot.ca.gov;rramos@altavistasolutions.com;corey.casey@dot.ca.gov;ehab.a.wahed@dot.ca.gov;allen.king@dot.ca.gov
CONTRACTOR:
Golden State Bridge
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