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:2017-09-20-15
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:
Structure foundation
FOR USE IN:
0 to 5 ft
SAMPLE FROM:
RC-17-002

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:
09/20/2017
BY: Michael Mifkovic
TITLE:
Unknown (Unknown)
DIST, CO, RTE, PM:
02-SHA,LAS,PLU,SHA,SIS,TRI-5-22087-25.7
CONT. NO.: DEA: 024F7804
FED. NO.:
LIMITS:
IN BUTTE, LASSEN, PLUMAS, SHASTA, SISKIYOU AND TRI
RECIPIENT(S):
CONTRACTOR:
Tullis Inc

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