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:2013-11-06-9549
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:
1x4 concrete aggregates
FOR USE IN:
SAMPLE FROM:
Hi-Grade Oro Grande

DEPTH:
LOCATION OF SOURCE:
1x4 Concrete Aggregates

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
1x4 Concrete Aggregates
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
11/06/2013
BY: Jimmy Sanchez
TITLE:
Field Technician ()
DIST, CO, RTE, PM:
08-SBD-40-R85.2
CONT. NO.: DEA: 080N5904
FED. NO.:
LIMITS:
SAN BERNARDINO COUNTY NEAR ESSEX AT VAN WINKLE WAS
RECIPIENT(S):
CONTRACTOR:
GRANITE CONSTRUCTION COMPANY

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