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:2021-03-02-22
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:
Bearing Pad
FOR USE IN:
SAMPLE FROM:
Manufacturer

DEPTH:
LOCATION OF SOURCE:
Scougal Rubber

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Scougal Rubber
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
03/02/2021
BY: Brad Streeter
TITLE:
()
DIST, CO, RTE, PM:
12-ORA-5-12.4/14.5
CONT. NO.: DEA: 120K0214
FED. NO.:
LIMITS:
ORANGE COUNTY IN SAN JUAN CAPISTRANO, LAGUNA HILLS
RECIPIENT(S): farid.zokai@dot.ca.gov;imad.karam@dot.ca.gov;venkatesh.iyer@dot.ca.gov
CONTRACTOR:
ORTIZ ENTERPRISES, INC.

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