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:2018-05-17-11
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:
9 ASTM A615 Grade 75 ASTM A934 Purple Epoxy Coated Threaded WFE Bars w/ nutes
FOR USE IN:
SAMPLE FROM:
Manufacturer

DEPTH:
LOCATION OF SOURCE:
Williams Form Engineering

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Williams Form Engineering
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
05/17/2018
BY: Greg Thompson
TITLE:
Associate Steel Inspector (Unknown)
DIST, CO, RTE, PM:
04-ALA-680-M2.4/M12.4
CONT. NO.: DEA: 044G0564
FED. NO.:
LIMITS:
FREMONT AND AT SUNOL FROM MISSION BOULEVARD SEPARA
RECIPIENT(S): mathew.abel@dot.ca.gov;eyip@altavistasolutions.com;jason.m.gramlick@dot.ca.gov;thomas.greg.thompson@dot.ca.gov;satinder.grewal@dot.ca.gov;jordan.jarosz@dot.ca.gov;jason.wilcox@dot.ca.gov
CONTRACTOR:
BAY CITIES PAVING & GRADING, INC.

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