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:2020-04-27-6
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:
Flash Welded Rebar Hoops
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
CMC Etiwanda

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 Etiwanda
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
04/27/2020
BY: Mike Kopenski
TITLE:
QA Inspector ((310) 745-9655)
DIST, CO, RTE, PM:
08-SBD-10-0.0/13.2
CONT. NO.: DEA: 080C2514
FED. NO.:
LIMITS:
LA/SBD County Line to PM 13.2 near I-15
RECIPIENT(S): michael.kopenski@dot.ca.gov;kenneth.l.varela@dot.ca.gov;LA.METS.Reports@dot.ca.gov;mantonelli@i-10express.com;mohamed.abdelbarr@dot.ca.gov
CONTRACTOR:
Lane-Security Paving Joint Venture

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