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: 2019-12-11-13
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:
3/4-10 x 3 1/4" A325 HVY HX MG NUT
FOR USE IN:
SAMPLE FROM:
Fabricator
DEPTH:
LOCATION OF SOURCE:
Structural and Steel Products
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Structural and Steel Products
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
12/11/2019
BY:
Jane Lillard
TITLE:
CALTRANS METS QA INSPECTOR (916-308-9430)
DIST, CO, RTE, PM:
02-SHA,LAS,PLU,SHA,SIS,TRI-5-22087-25.7
CONT. NO.:
DEA: 024F7804
FED. NO.:
LIMITS:
IN BUTTE, LASSEN, PLUMAS, SHASTA, SISKIYOU AND TRI
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
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