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: 2020-08-05-1
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 A722 All-Thread-Bar 150 KSI
FOR USE IN:
SAMPLE FROM:
Manufacturer

DEPTH:
LOCATION OF SOURCE:
Williams Form Engineering

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Williams Form Engineering
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
08/05/2020
BY: Arthur Peterson
TITLE:
QA Inspector (707-342-8602)
DIST, CO, RTE, PM:
07-VEN-33-22.16, 22.16
CONT. NO.: DEA: 071XM404
FED. NO.:
LIMITS:
Ventura County on Route 33 at PM.22.16.
RECIPIENT(S): kenneth.l.varela@dot.ca.gov;LA.METS.Reports@dot.ca.gov;arthur.peterson@dot.ca.gov;Alan.Davis@dot.ca.gov;aziz@goanalyzer.com;jeffrey.yu@dot.ca.gov
CONTRACTOR:
Case Pacific Contractors and Engineers

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