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:2018-08-23-2
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:
Threadbar
FOR USE IN:
SAMPLE FROM:
Fabricator

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:
08/23/2018
BY: Greg Johnston
TITLE:
QA (9165247768)
DIST, CO, RTE, PM:
04-MRN,SON-101-MRN27.0/27.6SON0.0/4.5
CONT. NO.: DEA: 042640N4
FED. NO.:
LIMITS:
MARIN AND SONOMA COUNTIES IN AND NEAR PETALUMA FRO
RECIPIENT(S): LA.Reports@dot.ca.gov;kenneth.l.varela@dot.ca.gov;gjohnston@altavistasolutions.com;jyotsna.sharma@dot.ca.gov;brian.f.beaudoin@dot.ca.gov;eyip@altavistasolutions.com
CONTRACTOR:
GHILOTTI CONSTRUCTION COMPANY

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