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:2019-05-16-3
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:
1" HMA-A R15 PG 64-28M (1.0% Lime Slurry)
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
Aggregate Industries Sloan, NV

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Aggregate Industries Sloan, NV
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
05/16/2019
BY: Larry Francisco
TITLE:
()
DIST, CO, RTE, PM:
08-SBD-15-174.0/175.0
CONT. NO.: DEA: 081G4604
FED. NO.:
LIMITS:
SAN BERNARDINO COUNTY FROM 2.5 MILES SOUTH OF BAIL
RECIPIENT(S):
CONTRACTOR:
GRANITE CONSTRUCTION COMPANY

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