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:2017-11-09-5
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:
7/8 A325 Assembly
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
St Louis Screw Bolt

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
St Louis Screw Bolt
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
11/09/2017
BY: Tory McLaurin
TITLE:
QA Inspector (6616185971)
DIST, CO, RTE, PM:
07-LA-5-42.8/47.3
CONT. NO.: DEA: 07121844
FED. NO.:
LIMITS:
LOS ANGELES COUNTY IN LOS ANGELES, GLENDALE, AND B
RECIPIENT(S): kenneth.l.varela@dot.ca.gov;LA.METS.Reports@dot.ca.gov;tminspection@yahoo.com;matthew.remo@dot.ca.gov;tony.d.le@dot.ca.gov
CONTRACTOR:
SECURITY PAVING COMPANY, INC.

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