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: 2020-09-02-39
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 w/RAP
FOR USE IN:
SAMPLE FROM:
Manufacturer
DEPTH:
LOCATION OF SOURCE:
Knife River Construction - Hallwood
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Knife River Construction - Hallwood
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
09/02/2020
BY:
Brad Mckeehan (WITNESS)
TITLE:
KRC Personnel ()
DIST, CO, RTE, PM:
03-BUT-70-5.6/9.1
CONT. NO.:
DEA: 033H72U4
FED. NO.:
LIMITS:
BUTTE COUNTY NEAR OROVILLE FROM 0.2 MILE NORTH OF
RECIPIENT(S):
CONTRACTOR:
BALDWIN CONTRACTING COMPANY INC. DBA. KNIFE RIVER CONSTRUC TION
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