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: 2020-09-02-29
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:
1x4
FOR USE IN:
SAMPLE FROM:
belt

DEPTH:
LOCATION OF SOURCE:
91-39-0021

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-39-0021
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
09/02/2020
BY: Matthew Horn
TITLE:
QC Technician (5592922188)
DIST, CO, RTE, PM:
03-SAC-99,160-4.5/5.7,R44.5
CONT. NO.: DEA: 033F5404
FED. NO.:
LIMITS:
SACRAMENTO COUNTY NEAR GALT ON ROUTE 99 FROM NORTH
RECIPIENT(S): (to be selected by data publishing engineer)
CONTRACTOR:

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