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:2020-05-21-7
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:
#4 Button Heads
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
Camblin

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Camblin
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
05/21/2020
BY: Kevin muser
TITLE:
qa (9165170532)
DIST, CO, RTE, PM:
02-MOD-299-0.5/1.0
CONT. NO.: DEA: 024F2104
FED. NO.:
LIMITS:
Construction of Butte Creek Bridge and Ash Creek B
RECIPIENT(S): kmuser@altavistasolutions.com;ryan.cummings@dot.ca.gov;mike.zdenek@dot.ca.gov;ryan.duran@dot.ca.gov;peter.gan@dot.ca.gov
CONTRACTOR:
WEST COAST CONTRACTORS

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