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:2019-07-23-2
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:
2 1/4" threaded bar
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
Williams Form Engineering

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Williams Form Engineering
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/23/2019
BY: Raymond Aludino
TITLE:
(9167300054)
DIST, CO, RTE, PM:
04-ALA-880-10.7
CONT. NO.: DEA: 044G8804
FED. NO.:
LIMITS:
ALAMEDA COUNTY IN FREMONT AT CRANDALL CREEK BRIDGE
RECIPIENT(S): Raymond.Aludino@dot.ca.gov;linda.phoen@dot.ca.gov;vincent.b.tang@dot.ca.gov;jason.wilcox@dot.ca.gov
CONTRACTOR:
Disney Construction

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