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: 2020-04-29-10
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:
HVY Hex Nut A194
FOR USE IN:
SAMPLE FROM:
Job Site

DEPTH:
LOCATION OF SOURCE:
Ningbo Haixin Hardware

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Ningbo Haixin Hardware
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
04/29/2020
BY: Dave Gunderson
TITLE:
DIST, CO, RTE, PM:
01-MEN-1-62.2/R78.9
CONT. NO.: DEA: 01362704
FED. NO.:
LIMITS:
MENDOCINO COUNTY NEAR FORT BRAGG FROM 0.1 MILE NOR
RECIPIENT(S): aaron.franklin@dot.ca.gov;ryan.cummings@dot.ca.gov;gino.del.chiaro@dot.ca.gov;Roozbeh.Hadipour@dot.ca.gov;levy.dumas@dot.ca.gov
CONTRACTOR:
GRANITE CONSTRUCTION COMPANY

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