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:2020-12-11-8
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 concrete aggregates
FOR USE IN:
(no information entered)
SAMPLE FROM:
belt cut

DEPTH:
LOCATION OF SOURCE:
91-42-0003

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-42-0003
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
12/11/2020
BY: Cody Cuevas
TITLE:
QC Technician ()
DIST, CO, RTE, PM:
05-SB-101-7.3/9.6
CONT. NO.: DEA: 050N73U4
FED. NO.:
LIMITS:
SUMMERLAND FROM 0.2 MILES NORTH OF PARDARO LANE OV
RECIPIENT(S):
CONTRACTOR:
GRANITE CONSTRUCTION COMPANY

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