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: 2020-04-09-7
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:
#6 A775 Rebar
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
Western Coatings

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Western Coatings
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
04/09/2020
BY: Kevin Muser
TITLE:
QA (9165170532)
DIST, CO, RTE, PM:
03-ED-50-R28.5/R29.1,R31.2
CONT. NO.: DEA: 030H3414
FED. NO.:
LIMITS:
EL DORADO COUNTY NEAR POLLOCK PINES FROM 0.3 MILE
RECIPIENT(S): ryan.cummings@dot.ca.gov;kevin.muser@dot.ca.gov;jody.phillips@dot.ca.gov;joe.harline@dot.ca.gov;donald.adams@dot.ca.gov
CONTRACTOR:
Flatiron West

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