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: 2017-07-17-1
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:
Threadbar
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
DSI

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
DSI
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/17/2017
BY: Jeff Sulka
TITLE:
Unknown (Unknown)
DIST, CO, RTE, PM:
01-DN-101-14.9/15.3
CONT. NO.: DEA: 010B27U4
FED. NO.:
LIMITS:
DEL NORTE COUNTY ABOUT 10 MILES NORTH OF KLAMATH F
RECIPIENT(S): jsulka@altavistasolutions.com;LA.METS.Reports@dot.ca.gov;kenneth.l.varela@dot.ca.gov;karen.sanders@dot.ca.gov;Brian.cinkutis@parsons.com;ncuellar@altavistasolutions.com
CONTRACTOR:
STEWART ENGINEERING INC

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