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:2016-03-22-6
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:
Foundation report
FOR USE IN:
25 ft
SAMPLE FROM:
R-16-041

DEPTH:
LOCATION OF SOURCE:
NA

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
NA
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
03/22/2016
BY: Ron Karpowicz
TITLE:
Unknown (Unknown)
DIST, CO, RTE, PM:
05-SB-101-2-12.3
CONT. NO.: DEA: 050N7004
FED. NO.:
LIMITS:
On route 101m from 0.2 Miles South of Bailard Aven
RECIPIENT(S):
CONTRACTOR:

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