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:2020-07-24-2
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:
HRC 120 T-Heads
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
HRC

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
HRC
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/24/2020
BY: Clifford William
TITLE:
QA Inspector (17142674733)
DIST, CO, RTE, PM:
12-ORA-405,73,405,605-9.3/24.3
CONT. NO.: DEA: 120H1004
FED. NO.:
LIMITS:
Orange and Los Angeles Counties: 12-ORA-405 PM 9.3
RECIPIENT(S): kenneth.l.varela@dot.ca.gov;LA.METS.Reports@dot.ca.gov;william.clifford@dot.ca.gov;halonso@HNTB.com;cal.zachman@jacobs.com;jinesh.mehta@dot.ca.gov
CONTRACTOR:
OC 405 Partners

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