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:2019-04-01-1
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:
#8 Threaded Bar with nuts
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
DSI

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
DSI
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
04/01/2019
BY: Arthur Peterson
TITLE:
QA Inspector (707-342-8602)
DIST, CO, RTE, PM:
04-CC-680-R11.0/R12.0
CONT. NO.: DEA: 040J3804
FED. NO.:
LIMITS:
CONTRA COSTA COUNTY AT ALAMO FROM 0.3 MILE SOUGHT
RECIPIENT(S): arthur.peterson@amecfw.com;kenneth.l.varela@dot.ca.gov;LA.METS.Reports@dot.ca.gov;jason.wilcox@dot.ca.gov
CONTRACTOR:
Ghilloti Construction Co.

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