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:2018-09-24-8
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:
Bearing Pad
FOR USE IN:
SAMPLE FROM:
Manufacturer

DEPTH:
LOCATION OF SOURCE:
DS Brown Seismic Energy

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
DS Brown Seismic Energy
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
09/24/2018
BY: Mike Spellman
TITLE:
Unknown (Unknown)
DIST, CO, RTE, PM:
02-SIS-96-R52.5/88.4
CONT. NO.: DEA: 024E6504
FED. NO.:
LIMITS:
SISKIYOU COUNTY NEAR SEIAD VALLEY AT VARIOUS LOCAT
RECIPIENT(S): tminspection@yahoo.com;kenneth.l.varela@dot.ca.gov;LA.METS.Reports@dot.ca.gov;fred.saylor@dot.ca.gov;david.p.murray@dot.ca.gov;mark.loader@dot.ca.gov;bob.thompson@dot.ca.gov;mfatemi@dot.ca.gov
CONTRACTOR:
J.F. Shea Construction, Inc

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