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:2019-11-13-3
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 x 3'-8" flash welded hoop
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
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
11/13/2019
BY: Steve Hall
TITLE:
CT METS QA INSPECTOR (6466327821)
DIST, CO, RTE, PM:
08-SBD-60-R0.7/R3.0
CONT. NO.: DEA: 080F0304
FED. NO.:
LIMITS:
IN SAN BERNARDINO COUNTY IN AND NEAR CHINO AT VARI
RECIPIENT(S): steven.hall@dot.ca.gov;richard.kim@hdrinc.com;julien.atallah@dot.ca.gov
CONTRACTOR:
SEMA CONSTRUCTION, INC.

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