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: 2017-07-28-15
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:
F1554 anchor bolt
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
BSMI

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
BSMI
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/28/2017
BY: Rob RAMOS
TITLE:
QA (916-996-2658)
DIST, CO, RTE, PM:
02-SIS-5-R7.2
CONT. NO.: DEA: 022E8004
FED. NO.:
LIMITS:
IN SISKIYOU COUNTY NEAR DUNSMUIR ATDUNSMUIR GRADE
RECIPIENT(S): rramos@altavistasolutions.com;gino.del.chiaro@dot.ca.gov;nicole.mallory@dot.ca.gov;andy.osulivan@dot.ca.gov;cgardner@altavistasolutions.com
CONTRACTOR:
RANDY HILL CONSTRUCTION, INC

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