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:2021-02-19-2
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:
A325 Fastener Assembly
FOR USE IN:
SAMPLE FROM:
Distributor

DEPTH:
LOCATION OF SOURCE:
Page Industrial

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Page Industrial
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
02/19/2021
BY: Brian Murray
TITLE:
QA Inspector (213 435 4055)
DIST, CO, RTE, PM:
07-LA-10-14.0/19.0
CONT. NO.: DEA: 07296604
FED. NO.:
LIMITS:
IN THE CITY OF LOS ANGELES, AT SANTA MONICA VIADUC
RECIPIENT(S): LA.METS.Reports@dot.ca.gov;brian.murray@dot.ca.gov;pravin.patel@dot.ca.gov;nabil.shmara@dot.ca.gov;jeffrey.yu@dot.ca.gov
CONTRACTOR:
CL Industrial Coating Inc.

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