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:2017-07-26-2
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:
HRC 120 T-Heads
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
Headed Reinforcement Corp, Fountain Valley, CA

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Headed Reinforcement Corp, Fountain Valley, CA
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/26/2017
BY: Paul Shrestha
TITLE:
CT METS QA INSPECTOR ((424) 298-7781)
DIST, CO, RTE, PM:
06-FRE-99-23.5/26.7
CONT. NO.: DEA: 062HT104
FED. NO.:
LIMITS:
State Highway 99 in Fresno (Fresno County) from 0.
RECIPIENT(S): LA.METS.Reports@dot.ca.gov;Justin.Kimura@dot.ca.gov;Daniel.Chapa@dot.ca.gov;kevin.couch@amecfw.com
CONTRACTOR:
GRANITE CONSTRUCTION COMPANY

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