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:2019-08-08-21
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:
7/8 - 9 x 7 A325
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
CK Johnson

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
CK Johnson
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
08/08/2019
BY: Jamie Doe
TITLE:
QA Inspector (916-838-4505)
DIST, CO, RTE, PM:
07-LA-47-.86
CONT. NO.: DEA: 071XH004
FED. NO.:
LIMITS:
RECIPIENT(S): jamie.doe@dot.ca.gov;gino.del.chiaro@dot.ca.gov;ryan.cummings@dot.ca.gov;thang.ton@dot.ca.gov;noah.c.bruton@dot.ca.gov;venkatesh.iyer@dot.ca.gov
CONTRACTOR:
GOLDEN STATE BRIDGE INC

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