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:2020-11-24-4
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:
#8 threaded bar
FOR USE IN:
SAMPLE FROM:
Fabricator

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:
11/24/2020
BY: Steve Hall
TITLE:
CT METS QA INSPECTOR (6466327821)
DIST, CO, RTE, PM:
08-SBD-215-4.5/5.8
CONT. NO.: DEA: 081H7704
FED. NO.:
LIMITS:
SAN BENARDINO COUNTY IN SAN BERNARDINO FROM 0.5 MI
RECIPIENT(S): steven.hall@dot.ca.gov;kenneth.l.varela@dot.ca.gov;LA.METS.Reports@dot.ca.gov;nicholas.mineo@dot.ca.gov;julien.atallah@dot.ca.gov
CONTRACTOR:
BEADOR CONSTRUCTION COMPANY INC

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