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:2017-05-26-4
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:
1x8x10 Beraing Pad
FOR USE IN:
SAMPLE FROM:
Manufacturer

DEPTH:
LOCATION OF SOURCE:
Scougal Rubber

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Scougal Rubber
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
05/26/2017
BY: Kevin Muser
TITLE:
QA (916-799-3391)
DIST, CO, RTE, PM:
01-MEN-162-13.9,22.7
CONT. NO.: DEA: 010B5404
FED. NO.:
LIMITS:
MENDOCINO COUNTY NEAR DOS RIOS AT 1.2 MILES WEST O
RECIPIENT(S): gino.del.chiaro@dot.ca.gov;kmuser@altavistasolutions.com;rramos@altavistasolutions.com;c.n.bapat@dot.ca.gov;ncuellar@altavistasolutions.com
CONTRACTOR:
GRANITE CONSTRUCTION COMPANY

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