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: 2019-07-01-19
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-inch Type A HMA (PG 64-28 M), 1.1 Lime, 10 RAP
FOR USE IN:
SAMPLE FROM:
Manufacturer

DEPTH:
LOCATION OF SOURCE:
Eagle Peak Rock and Paving, Alturas, CA

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 Rock and Paving, Alturas, CA
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/01/2019
BY: Cindy Bryant
TITLE:
DIST, CO, RTE, PM:
02-MOD-299-Var
CONT. NO.: DEA: 023H1704
FED. NO.:
LIMITS:
MODOC COUNTY IN AND NEAR ALTURAS AT VARIOUS LOCATI
RECIPIENT(S):
CONTRACTOR:
EAGLE PEAK ROCK & PAVING INC

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