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:2019-05-29-1
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:
A722 Threaded Bar
FOR USE IN:
SAMPLE FROM:
Distributor

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:
05/29/2019
BY: Lorenzo Lorenzo
TITLE:
QA (702 917-2503)
DIST, CO, RTE, PM:
03-ED-50-67.3
CONT. NO.: DEA: 033F5304
FED. NO.:
LIMITS:
EL DORADO COUNTY NEAR MEYERS AT ECHO SUMMIT SIDEHI
RECIPIENT(S): gino.del.chiaro@dot.ca.gov;robert.ramos@dot.ca.gov;lgarcia@altavistasolutions.com;kenneth.l.varela@dot.ca.gov;LA.METS.Reports@dot.ca.gov;nathan.alterton@dot.ca.gov;Brandon.Miller@dot.ca.gov;justin.palmaymesa@dot.ca.gov;hitesh.h.patel@dot.ca.gov
CONTRACTOR:
Q & D CONSTRUCTION, INC

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