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:2018-05-17-4
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:
A706 T-headed rebar
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
Harris Rebar

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Harris Rebar
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
05/17/2018
BY: Ed Fleming
TITLE:
TET (7073102029)
DIST, CO, RTE, PM:
04-ALA-880-28.4/29.2
CONT. NO.: DEA: 040A7104
FED. NO.:
LIMITS:
ALAMEDA COUNTY IN ALAMEDA AND OAKLAND FROM 0.2 MIL
RECIPIENT(S): jason.gramlick@dot.ca.gov;ed.fleming@dot.ca.gov;eyip@altavistasolutions.com;mathew.abel@dot.ca.gov;joy.k.cheung@dot.ca.gov;maxime.dabilly@dot.ca.gov;jason.wilcox@dot.ca.gov
CONTRACTOR:
RGW Construction

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