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: 2020-08-25-22
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:
#10 Test, No Test #09(023133),#11(023694),#12(023698), #13(023696)
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
San Joaquin Refining Co Inc

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
San Joaquin Refining Co Inc
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
08/25/2020
BY: G Avarez
TITLE:
Consultant ()
DIST, CO, RTE, PM:
05-SLO-101-16.5/R21.5
CONT. NO.: DEA: 051M0004
FED. NO.:
LIMITS:
SAN LUIS OBISPO COUNTY IN AND NEAR PISMO BEACH FRO
RECIPIENT(S): (to be selected by data publishing engineer)
CONTRACTOR:

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