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:2020-09-29-10
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:
1/2" domestic HDG ASTM F436 hardened washers.
FOR USE IN:
SAMPLE FROM:
Distributor

DEPTH:
LOCATION OF SOURCE:
Portland Bolt

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Portland Bolt
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
09/29/2020
BY: Roland Maynard
TITLE:
QA Inspector ((51) 774-1269)
DIST, CO, RTE, PM:
02-SHA-273-
CONT. NO.: DEA: 021J2404
FED. NO.:
LIMITS:
RECIPIENT(S): roland.maynard@dot.ca.gov;ryan.cummings@dot.ca.gov;mike.zdenek@dot.ca.gov;peter.gan@dot.ca.gov
CONTRACTOR:
CAL ELECTRO, INC.

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