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:2018-10-19-1
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:
A615 Grade 75 Threaded Bar with A108 Nut
FOR USE IN:
SAMPLE FROM:
Manufacturer

DEPTH:
LOCATION OF SOURCE:
Williams Form San Diego

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 San Diego
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
10/19/2018
BY: David Weeks
TITLE:
QA (310-883-8369)
DIST, CO, RTE, PM:
07-LA-110,405-8.0/9.0,12.2/13.2
CONT. NO.: DEA: 07293704
FED. NO.:
LIMITS:
LOS ANGELES COUNTY IN AND NEAR CARSON ON ROUTE 110
RECIPIENT(S): kenneth.l.varela@dot.ca.gov;greg.alexander@dot.ca.gov;bdagher@altavistasolutions.com;LA.METS.Reports@dot.ca.gov;david.weeks@dot.ca.gov
CONTRACTOR:
OHL USA, INC

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