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: 2018-05-30-1
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:
1 3/8 threadbar / nut
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
DSI

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
DSI
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
05/30/2018
BY: Greg Johnston
TITLE:
QA (9165247768)
DIST, CO, RTE, PM:
01-MEN-1-78.0/83.5, 77.0/83.5
CONT. NO.: DEA: 010G8004
FED. NO.:
LIMITS:
In Mendocino County near West port from 0.3 mile s
RECIPIENT(S): gjohnston@altavistasolutions.com;kenneth.l.varela@dot.ca.gov;LA.METS.Reports@dot.ca.gov;grant.krueger@dot.ca.gov;moussa.jandal@dot.ca.gov;tjanvelyan@altavistasolutions.com
CONTRACTOR:
MCM Construction

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