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:2020-07-15-6
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:
ASTM A325 1-1/4"x 4" Bolt
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
Structural and Steel Products

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Structural and Steel Products
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/15/2020
BY: Michael Kopenski
TITLE:
QA ((310) 745-9655)
DIST, CO, RTE, PM:
04-SM-101-0.0/21.8
CONT. NO.: DEA: 041J5694
FED. NO.:
LIMITS:
SANTA CLARA AND SAN MATEO COUNTIES FROM 0.3 MILE N
RECIPIENT(S): kenneth.l.varela@dot.ca.gov;LA.METS.Reports@dot.ca.gov;scott.mccrank@dot.ca.gov;tyler.pinell@dot.ca.gov;ikwan@altavistasolutions.com
CONTRACTOR:
KIEWIT INFRASTRUCTURE COMPANY

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