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: 2018-12-28-4
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:
Barsplice Zap Screwlok Coupler & Bartec Couplers
FOR USE IN:
SAMPLE FROM:
Job Site

DEPTH:
LOCATION OF SOURCE:
Barsplice, Dextra America, Nucor

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Barsplice, Dextra America, Nucor
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
12/28/2018
BY: Emiliano Berntsen
TITLE:
Unknown (Unknown)
DIST, CO, RTE, PM:
05-SB-101-2.2/3.3
CONT. NO.: DEA: 054482U4
FED. NO.:
LIMITS:
SANTA BARBARA COUNTY IN CARPINTERIA FROM 0.2 MILE
RECIPIENT(S): jason.m.gramlick@dot.ca.gov;LA.METS.Reports@dot.ca.gov;kenneth.l.varela@dot.ca.gov;jason.kline@dot.ca.gov;raymond.barajas@dot.ca.gov;elaine.yip@dot.ca.gov
CONTRACTOR:
SECURITY PAVING COMPANY, INC.

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