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: 2019-04-25-19
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:
1.0" Washed PCC Aggregate
FOR USE IN:
Unknown
SAMPLE FROM:
Stockpile @ Plant

DEPTH:
LOCATION OF SOURCE:
91-19-0001

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-19-0001
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
04/25/2019
BY: Paul Reno
TITLE:
Plant QC ()
DIST, CO, RTE, PM:
07-LA-14-R35.0/R53.5
CONT. NO.: DEA: 07312804
FED. NO.:
LIMITS:
LOS ANGELES COUNTY AT VARIOUS LOCATIONS FROM 0.7 M
RECIPIENT(S):
CONTRACTOR:
Dreambuilder Construction Corporation

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