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: 2017-12-22-12
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:
3 4 in Aggregate Sample
FOR USE IN:
7753550420
SAMPLE FROM:
Coarse aggregate pile at source

DEPTH:
LOCATION OF SOURCE:
Aggregate Source ID

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Aggregate Source ID
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
12/22/2017
BY: Aggregate First Name Aggregate Last Name
TITLE:
Aggregate Engineer (7753550420)
DIST, CO, RTE, PM:
03-SAC,OMG-888,99,80-0.6-0.6
CONT. NO.: DEA: 0322222
FED. NO.:
LIMITS:
THIS PROJECT RECORD WAS ADDED FOR DIME TESTERS -
RECIPIENT(S):
CONTRACTOR:

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