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:2017-09-07-1
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:
A775 Epoxy Coated Dowel Baskets
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
Dayton Superior

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Dayton Superior
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
09/07/2017
BY: Rob Ramos
TITLE:
QA (916-996-2658)
DIST, CO, RTE, PM:
10-SJ-132-0.4/7.1
CONT. NO.: DEA: 100G8204
FED. NO.:
LIMITS:
SAN JOAQUIN COUNTY NEAR VERNALIS FROM 0.4 MILE EAS
RECIPIENT(S): gino.del.chiaro@dot.ca.gov;rramos@altavistasolutions.com;mohammad.waziri@dot.ca.gov;mohsen.abdelfatah@dot.ca.gov;allen.king@dot.ca.gov
CONTRACTOR:
BAY CITIES PAVING & GRADING, INC.

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