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:2021-03-05-5
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:
Anchor bolt 2.25" x 55" F1554-55 HDG
FOR USE IN:
SAMPLE FROM:
Manufacturer

DEPTH:
LOCATION OF SOURCE:
Madden Bolt

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Madden Bolt
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
03/05/2021
BY: Mark Lara
TITLE:
CT METS QA INSPECTOR (610-662-4557)
DIST, CO, RTE, PM:
03-ED-50-0.0/80.4
CONT. NO.: DEA: 030H5204
FED. NO.:
LIMITS:
EL DORADO COUNTY AT VARIOUS LOCATIONS FROM THE SAC
RECIPIENT(S): mlara@pennoni.com;jason.m.gramlick@dot.ca.gov;juanah.koker@dot.ca.gov;donald.adams@dot.ca.gov;Aaron.Franklin@dot.ca.gov
CONTRACTOR:
TIM PAXIN'S PACIFIC EXCAVATION INC

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