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: 2018-01-01-15
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:
Brief description of sample
FOR USE IN:
Southwest footing of the Lone Tree Canal abut
SAMPLE FROM:
Plant Stockpile

DEPTH:
LOCATION OF SOURCE:
Smara 1234

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Smara 1234
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
01/01/2018
BY: Jack Jones
TITLE:
Field Technician (1-916-555-1212)
DIST, CO, RTE, PM:
03-SAC,OMG-888,99,80-0.6-0.6
CONT. NO.: DEA: 00000000
FED. NO.:
LIMITS:
THIS PROJECT RECORD WAS ADDED FOR DIME DEVELOPERS
RECIPIENT(S): (to be selected by data publishing engineer)
CONTRACTOR:

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