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: 2013-08-02-9602
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:
1/2 HMA
FOR USE IN:
SAMPLE FROM:
Sample pad

DEPTH:
LOCATION OF SOURCE:
Eagle Peak

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Eagle Peak
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
08/02/2013
BY: Josh Dorney
TITLE:
Materials Tester ()
DIST, CO, RTE, PM:
02-SIS-5-R50.9/R58.2
CONT. NO.: DEA: 023E7604
FED. NO.:
LIMITS:
SISKIYOU COUNTY NEAR YREKA FROM 0.3 MILE SOUTH OF
RECIPIENT(S):
CONTRACTOR:
ROAD AND HIGHWAY BUILDERS OF CALIFORNIA, INC.

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