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:2018-01-09-3
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:
ASTM A416 seven wire uncoated steel strand
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
Confab Shafter

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Confab Shafter
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
01/09/2018
BY: Ryan Cummings
TITLE:
QA (916-718-7759)
DIST, CO, RTE, PM:
06-FRE-180-R74.1/R78.6
CONT. NO.: DEA: 06342534
FED. NO.:
LIMITS:
FRESNO COUNTY ABOUT 8.4 MILES EAST OF FRESNO FROM
RECIPIENT(S): rramos@altavistasolutions.com;gino.del.chiaro@dot.ca.gov;rcummings@hrvinspectors.com;mike.bloom@dot.ca.gov;justin.palmaymesa@dot.ca.gov
CONTRACTOR:
SECURITY PAVING COMPANY, INC.

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