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: 2020-04-23-1
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:
Material was subject to fire and high heat. Testing will provide acceptance of material. Varied sizes of steel reinforcement bars cut from field. and set of control from same heat
FOR USE IN:
SAMPLE FROM:
Job Site

DEPTH:
LOCATION OF SOURCE:
CMC

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
CMC
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
04/23/2020
BY: Nicholas Hoffmann
TITLE:
Assistant METS Representative (5105429827)
DIST, CO, RTE, PM:
12-ORA-405,73,405,605-9.3/24.3
CONT. NO.: DEA: 120H1004
FED. NO.:
LIMITS:
Orange and Los Angeles Counties: 12-ORA-405 PM 9.3
RECIPIENT(S):
CONTRACTOR:
OC 405 Partners

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