Sample Identification Card TL-0101

You may optionally email a link to the detail page for this sample to project or other relevant personnel. For better printouts, please be sure to print the form using landscape orientation and 100% paper size.

×
STATE OF CALIFORNIA ● DEPARTMENT OF TRANSPORTATION
SAMPLE IDENTIFICATION CARD
TL-0101 (REV. 02/17)
DIME Sample ID:2020-11-17-20
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" HMA-A-SP R25 0.8% Dry Lime
FOR USE IN:
Asphalt Paving
SAMPLE FROM:
Belt Cut at Granite Littlerock Plant

DEPTH:
LOCATION OF SOURCE:
91-19-0046, 91-19-0008

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-19-0046, 91-19-0008
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
11/17/2020
BY: Granite Construction Company Littlerock QC
TITLE:
()
DIST, CO, RTE, PM:
09-KER-14-R4.7/R12.6
CONT. NO.: DEA: 09367404
FED. NO.:
LIMITS:
KERN COUNTY AT AND NEAR ROSAMOND AND MOJAVE FROM 1
RECIPIENT(S):
CONTRACTOR:
Jesus Pena

To edit data on this form, you must be logged in to DIME and have sufficient privileges to edit the sample information.