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: 2018-03-19-14
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:
A722 HDG Threaded Bars
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
Coastal Fabrication

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Coastal Fabrication
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
03/19/2018
BY: James Doe
TITLE:
QA Inspector ((503) 918-4918)
DIST, CO, RTE, PM:
05-MON-68-4.04
CONT. NO.: DEA: 05937704
FED. NO.:
LIMITS:
County of Monterey
RECIPIENT(S): jason.m.gramlick@dot.ca.gov;eyip@altavistasolutions.com;jdoe@altavistasolutions.com;ignacio.saavedra@dot.ca.gov;Tim.OHalloran@weareharris.com;neil.weller@dot.ca.gov;bkrol@altavistasolutions.com
CONTRACTOR:
Garney Construction Company

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