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: 2019-11-14-21
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:
Epoxy Coated Rebar
FOR USE IN:
SAMPLE FROM:
Job Site

DEPTH:
LOCATION OF SOURCE:
Harris Rebar

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Harris Rebar
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
11/14/2019
BY: B Miller
TITLE:
DIST, CO, RTE, PM:
10-ALP-89-21.47
CONT. NO.: DEA: 101L1504
FED. NO.:
LIMITS:
RECIPIENT(S): iqbal.aulakh@dot.ca.gov;brandon.miller@dot.ca.gov;david.p.murray@dot.ca.gov
CONTRACTOR:
Q & D CONSTRUCTION, INC

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