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: 2017-08-03-2
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:
F1554 Grade 55 HDG Anchor Bolts
FOR USE IN:
SAMPLE FROM:
Source
DEPTH:
LOCATION OF SOURCE:
Blue Circle Corp
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Blue Circle Corp
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
08/03/2017
BY:
Tory McLaurin
TITLE:
QA (6616185971)
DIST, CO, RTE, PM:
03-ED-50-75.4/77.3
CONT. NO.:
DEA: 033C3804
FED. NO.:
LIMITS:
EL DORADO COUNTY IN SOUTH LAKE TAHOE FROM NORTH JU
RECIPIENT(S):
tminspection@yahoo.com;LA.METS.Reports@dot.ca.gov;kenneth.l.varela@dot.ca.gov;Jaret_Montplaisir@dot.ca.gov;allen.king@dot.ca.gov
CONTRACTOR:
SECURITY PAVING COMPANY, INC.
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