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: 2018-11-28-15
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:
3/8 PCC Pea Gravel
FOR USE IN:
Unknown
SAMPLE FROM:
Stockpile

DEPTH:
LOCATION OF SOURCE:
91-49-0062::HEALDSBURG TERRACE PHASE VI

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-49-0062::HEALDSBURG TERRACE PHASE VI
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
11/28/2018
BY: CJ Sousa
TITLE:
Plant QC ()
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):
CONTRACTOR:
GHILOTTI CONSTRUCTION COMPANY

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