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:2021-03-25-1
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:
No 10 A615 Gr 75 Epoxy Coated Threaded Bar
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
Williams Form Engineering San Diego

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Williams Form Engineering San Diego
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
03/25/2021
BY: David Weeks
TITLE:
ASI (310-883-8369)
DIST, CO, RTE, PM:
04-ALA-84-13.33
CONT. NO.: DEA: 04160304
FED. NO.:
LIMITS:
IN FREMONT, AT ALAMEDA CREEK BRIDGE (BR 33-0036).
RECIPIENT(S): david.weeks@dot.ca.gov;LA.METS.Reports@dot.ca.gov;yannaing.tun@dot.ca.gov;oanh.bui@dot.ca.gov;rommoney.wu@dot.ca.gov
CONTRACTOR:
VIKING CONSTRUCTION COMPANY

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