Sample Identification Card TL-0101

You may optionally email a link to the detail page for this sample to project or other relevant personnel. For better printouts, please be sure to print the form using landscape orientation and 100% paper size.

×
STATE OF CALIFORNIA ● DEPARTMENT OF TRANSPORTATION
SAMPLE IDENTIFICATION CARD
TL-0101 (REV. 02/17)
DIME Sample ID:2021-02-22-2
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:
Couplers
FOR USE IN:
SAMPLE FROM:
Manufacturer

DEPTH:
LOCATION OF SOURCE:
Dayton Superior

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Dayton Superior
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
02/22/2021
BY: Clint Williams
TITLE:
()
DIST, CO, RTE, PM:
04-ALA-880-14.5
CONT. NO.: DEA: 041W2104
FED. NO.:
LIMITS:
Industrial Blvd OC, NB 880 (bridge 33-0398)
RECIPIENT(S): joy.k.cheung@dot.ca.gov;Alexander.A.J.Schmitt@dot.ca.gov;rommoney.wu@dot.ca.gov
CONTRACTOR:
Ghilotti Construction Company

To edit data on this form, you must be logged in to DIME and have sufficient privileges to edit the sample information.