Sample Identification Card TL-0101

You may optionally email a link to the detail page for this sample to project or other relevant personnel. For better printouts, please be sure to print the form using landscape orientation and 100% paper size.

×
STATE OF CALIFORNIA ● DEPARTMENT OF TRANSPORTATION
SAMPLE IDENTIFICATION CARD
TL-0101 (REV. 02/17)
DIME Sample ID:2018-07-19-6
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:
A934 Expoxy Rebar
FOR USE IN:
SAMPLE FROM:
Manufacturer

DEPTH:
LOCATION OF SOURCE:
Fletcher Coating Co

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Fletcher Coating Co
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/19/2018
BY: William Clifford
TITLE:
QA Inspector ()
DIST, CO, RTE, PM:
04-SF-80-8.0/8.3,0.9/1.4
CONT. NO.: DEA: 04013584
FED. NO.:
LIMITS:
In San Francisco and Alameda Counties on Yerba Bue
RECIPIENT(S): kenneth.l.varela@dot.ca.gov;LA.METS.Reports@dot.ca.gov;wclifford@altavistasolutions.com;jsulka@altavistasolutions.com;brian.boal@dot.ca.gov;cmcdermott@altavistasolutions.com
CONTRACTOR:
Kiewit/Manson, AJV

To edit data on this form, you must be logged in to DIME and have sufficient privileges to edit the sample information.