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:2020-06-24-6
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:
Double headed rebar
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
Pacific Steel Group

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Pacific Steel Group
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
06/24/2020
BY: Paul Farinha
TITLE:
Asi ()
DIST, CO, RTE, PM:
03-SIE-49-9.2/24.7
CONT. NO.: DEA: 034H1004
FED. NO.:
LIMITS:
SIERRA COUNTY ON ROUTE 49 AT VARIOUS LOCATIONS
RECIPIENT(S): ryan.cummings@dot.ca.gov;paul.farinha@dot.ca.gov;christopher.fallbeck@dot.ca.gov;donald.adams@dot.ca.gov
CONTRACTOR:
GORDON N BALL INC

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