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: 2017-06-02-14
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:
virgin aggregate
FOR USE IN:
JMF
SAMPLE FROM:
Manufacturer

DEPTH:
LOCATION OF SOURCE:
Eagle Peak Rock and Paving, Alturas, 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:
Eagle Peak Rock and Paving, Alturas, CA
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
06/02/2017
BY: Dave Lockett
TITLE:
Tester (Unknown)
DIST, CO, RTE, PM:
02-LAS,MOD-395-119.0/128.7,39.9/61.6
CONT. NO.: DEA: 022H3304
FED. NO.:
LIMITS:
LASSEN AND MODOC COUNTIES ON ROUTE 395 FROM 1.7 MI
RECIPIENT(S):
CONTRACTOR:
AMERICAN PAVEMENT SYSTEMS, INC.

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