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:2020-07-23-34
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:
3/4 RHMA-G
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
Teichert Materials Vernalis

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Teichert Materials Vernalis
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/23/2020
BY: CTInspectorIArechiga CTInspectorIArechiga
TITLE:
()
DIST, CO, RTE, PM:
04-CC-4-R32.7/R34.0
CONT. NO.: DEA: 044Q1604
FED. NO.:
LIMITS:
CONTRA COSTA COUNTY IN ANTIOCH AND BRENTWOOD FROM
RECIPIENT(S):
CONTRACTOR:

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