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:2017-06-21-3
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:
12x18x2
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:
06/21/2017
BY: Kevin Muser
TITLE:
Qa (9165170532)
DIST, CO, RTE, PM:
04-SOL-780-7.07
CONT. NO.: DEA: 044G4504
FED. NO.:
LIMITS:
LAUREL STREET OC
RECIPIENT(S): kmuser@altavistasolutions.com;gino.del.chiaro@dot.ca.gov;rramos@altavistasolutions.com;jolie.schneider@dot.ca.gov;joe.de.la.torre@dot.ca.gov;maged.g.armanuse@dot.ca.gov
CONTRACTOR:
R N R CONSTRUCTION, INC.

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