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:2017-11-16-1
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:
A934 Purple Epoxy Coated Rebar
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
Fletcher Coating Co

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Fletcher Coating Co
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
11/16/2017
BY: greg Jojnston
TITLE:
QA Inspector (9165247768)
DIST, CO, RTE, PM:
11-SD-8-T0.5/R0.7
CONT. NO.: DEA: 11408604
FED. NO.:
LIMITS:
SAN DIEGO COUNTY IN SAN DIEGO FROM NIMITZ BOULEVAR
RECIPIENT(S): claire.dodge@dot.ca.gov;gjohnston@altavistasolutions.com;kenneth.l.varela@dot.ca.gov;LA.METS.Reports@dot.ca.gov;khassan@altavistasolutions.com;cmargarito@altavistasolutions.com
CONTRACTOR:
HAZARD CONSTRUCTION COMPANY

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