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:2021-02-09-16
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:
ASTM F436 washers 1" diam.
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
CK Johnson

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
CK Johnson
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
02/09/2021
BY: Mahlon Lindenmuth
TITLE:
QA Inspector (646-740-3704)
DIST, CO, RTE, PM:
10-SJ-5-26.4/27.0
CONT. NO.: DEA: 101C9404
FED. NO.:
LIMITS:
ON STATE HIGHWAY IN SAN JOAQUIN COUNTY IN STOCKTON
RECIPIENT(S): ryan.cummings@dot.ca.gov;mahlon.lindenmuth@dot.ca.gov;chris.hanson@dot.ca.gov;ron.matin@dot.ca.gov;rajalingham.valluvan@dot.ca.gov
CONTRACTOR:
GOLDEN STATE BRIDGE, INC.

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