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: 2020-07-31-3
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:
A325 ROCAP ASSEMBLY
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
Utah Pacific Bridge and Steel

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Utah Pacific Bridge and Steel
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/31/2020
BY: Mahlon Lindenmuth
TITLE:
QA Inspector (646-740-3704)
DIST, CO, RTE, PM:
10-SJ,STA-99-0.0-0.7:24.4-24.8
CONT. NO.: DEA: 100L0204
FED. NO.:
LIMITS:
ON ROUTE 99 IN RIPON AT THE COUNTY LINE OF SAN JOA
RECIPIENT(S): ryan.cummings@dot.ca.gov;mahlon.lindenmuth@dot.ca.gov;harminder.deol@dot.ca.gov;george.samuel@dot.ca.gov;robert.ferris@dot.ca.gov
CONTRACTOR:
MCM Construction

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