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:2017-07-18-1
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:
10 HRC 120 End Anchors
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
HRC

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
HRC
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/18/2017
BY: Tory McLaurin
TITLE:
QA (6616185971)
DIST, CO, RTE, PM:
05-SLO,MON-101-63.2/R69.3,R0.0/R1.9
CONT. NO.: DEA: 050G0404
FED. NO.:
LIMITS:
SAN LUIS OBISPO AND MONTERY COUNTIES NEAR PASO ROB
RECIPIENT(S): tminspection@yahoo.com;LA.METS.Reports@dot.ca.gov;kenneth.l.varela@dot.ca.gov;amy.c.norris@dot.ca.gov;tyler.pinell@dot.ca.gov;jason.wilcox@dot.ca.gov
CONTRACTOR:
SECURITY PAVING COMPANY, INC.

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