Sample Identification Card TL-0101

You may optionally email a link to the detail page for this sample to project or other relevant personnel. For better printouts, please be sure to print the form using landscape orientation and 100% paper size.

STATE OF CALIFORNIA ● DEPARTMENT OF TRANSPORTATION
SAMPLE IDENTIFICATION CARD
TL-0101 (REV. 02/17)
DIME Sample ID: 2019-07-09-7
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:
1/2 HMA-A-SP R15
FOR USE IN:
Unknown
SAMPLE FROM:
Belt Cut at Plant

DEPTH:
LOCATION OF SOURCE:
91-36-0046, 91-36-0106

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-36-0046, 91-36-0106
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/09/2019
BY: A S SAMANO MAQUIBAN
TITLE:
DIST, CO, RTE, PM:
08-SBD-395-35.5/39.1
CONT. NO.: DEA: 080N9724
FED. NO.:
LIMITS:
SAN BERNARDINO COUNTY NEAR ADELANTO FROM 1.3 MILES
RECIPIENT(S): (to be selected by data publishing engineer)
CONTRACTOR:

To edit data on this form, you must be logged in to DIME and have sufficient privileges to edit the sample information.