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:2019-10-22-2
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:
F3125 Grade F1852 1" x 2-3/4" Fastener
FOR USE IN:
SAMPLE FROM:
Distributor

DEPTH:
LOCATION OF SOURCE:
Bristol Machine

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Bristol Machine
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
10/22/2019
BY: Arthur Peterson
TITLE:
QA Inspector (707-342-8602)
DIST, CO, RTE, PM:
08-SBD-15-42.5/46.0
CONT. NO.: DEA: 083555V4
FED. NO.:
LIMITS:
SAN BERNARDINO COUNTY IN VICTORVILLE FROM 0.5 MILE
RECIPIENT(S): kenneth.l.varela@dot.ca.gov;LA.METS.Reports@dot.ca.gov;jsulka@altavistasolutions.com;jeff.sulka@dot.ca.gov;srl-concrete@dot.ca.gov;arthur.peterson@dot.ca.gov;julien.atallah@dot.ca.gov
CONTRACTOR:
Ames Construction

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