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: 2017-06-14-5
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:
Fabricator

DEPTH:
LOCATION OF SOURCE:
UIS

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
UIS
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
06/14/2017
BY: David Flygare
TITLE:
CT METS QA INSPECTOR ((801) 669-2984)
DIST, CO, RTE, PM:
02-PLU-70-50.6/51.7
CONT. NO.: DEA: 022C0904
FED. NO.:
LIMITS:
PLUMAS COUNTY NEAR QUINCY FROM 0.6 MILE WEST TO 0.
RECIPIENT(S): dflygare@axiomes.net;jason.m.gramlick@dot.ca.gov;sramirez@altavistasolutions.com;Ronald.Collins@dot.ca.gov;jeff.rothgery@dot.ca.gov;cgardner@altavistasolutions.com
CONTRACTOR:
MCM Construction

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