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: 2019-08-02-2
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:
#6 Flash Welded Hoops
FOR USE IN:
SAMPLE FROM:
Fabricator
DEPTH:
LOCATION OF SOURCE:
RKR Steel Welding
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
RKR Steel Welding
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
08/02/2019
BY:
Hitesh Patel
TITLE:
Quality Assurance Inspector (9168691602)
DIST, CO, RTE, PM:
02-SIS-96-R52.5/88.4
CONT. NO.:
DEA: 024E6504
FED. NO.:
LIMITS:
SISKIYOU COUNTY NEAR SEIAD VALLEY AT VARIOUS LOCAT
RECIPIENT(S):
kenneth.l.varela@dot.ca.gov;LA.METS.Reports@dot.ca.gov;hitesh.h.patel@dot.ca.gov;mark.loader@dot.ca.gov;bob.thompson@dot.ca.gov;peter.gan@dot.ca.gov
CONTRACTOR:
J.F. Shea Construction, Inc
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