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: 2020-03-12-1
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" x 38" A449/A153 Hex Bolts
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
UIS Lindon UT

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
UIS Lindon UT
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
03/12/2020
BY: Sherri Brannon
TITLE:
CT METS QA INSPECTOR (916-8266371)
DIST, CO, RTE, PM:
04-NAP-128-20.1/20.4
CONT. NO.: DEA: 044G8404
FED. NO.:
LIMITS:
NAPA COUNTY ABOUT 15 MILES EAST OF RUTHERFORD FROM
RECIPIENT(S): jason.m.gramlick@dot.ca.gov;sherri.brannon@dot.ca.gov;darren.isada@dot.ca.gov;joe.delatorre@dot.ca.gov;mathew.abel@dot.ca.gov
CONTRACTOR:
GORDON N BALL INC

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