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: 2019-03-19-1
DIST LAB NO.
P.O. OR REQ. NO.
SAMPLE SENT TO:
A brief description of the sample
FOR USE IN:
A detailed description of where the material sample was collected
LOCATION OF SOURCE:
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
TEST RESULTS DESIRED
TOTAL QUANTITY AVAILABLE
BY: First name of sampler or witnessed by Last name of sampler or witnessed by
DIST, CO, RTE, PM:
CONT. NO.: DEA: APP
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