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:2019-10-07-23
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:
Rock and Sand
FOR USE IN:
Unknown
SAMPLE FROM:
Unknown

DEPTH:
LOCATION OF SOURCE:
91-19-0027: Corona

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-19-0027: Corona
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
10/07/2019
BY: Dwayne Ovalle
TITLE:
QC Field Technician (Unknown)
DIST, CO, RTE, PM:
07-LA,ORA-5-0.0/1.5, 44.3/44.4
CONT. NO.: DEA: 072159U4
FED. NO.:
LIMITS:
LOS ANGELES AND ORANGE COUNTIES IN BUENA PARK, LA
RECIPIENT(S):
CONTRACTOR:
SECURITY PAVING COMPANY, INC.

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