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:2021-02-16-2
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:
#6 x 5'-0" dia. flash welded hoops
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
RKR Steel Welding

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
RKR Steel Welding
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
02/16/2021
BY: Osiel Ramirez
TITLE:
Quality Assurance Inspector (5599740870)
DIST, CO, RTE, PM:
12-ORA-5-14.5/17.1
CONT. NO.: DEA: 120K0224
FED. NO.:
LIMITS:
ORANGE COUNTY IN MISSION VIEJO AND LAGUNA HILLS FR
RECIPIENT(S): Osiel.Ramirez@dot.ca.gov;LA.METS.Reports@dot.ca.gov;john.hong@dot.ca.gov;sara.soleimani@dot.ca.gov;venkatesh.iyer@dot.ca.gov
CONTRACTOR:
Flatiron West, Inc

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