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: 2021-03-25-13
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:
Asphalt Binder
FOR USE IN:
SAMPLE FROM:
Other

DEPTH:
LOCATION OF SOURCE:
Porterville Asphalt

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Porterville Asphalt
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
03/25/2021
BY: Brandon Burkey
TITLE:
TET ()
DIST, CO, RTE, PM:
06-TUL-65,190-0.0/R15.1,8.0/26.5
CONT. NO.: DEA: 060X0404
FED. NO.:
LIMITS:
TULARE COUNTY NEAR PORTERVILLE ON ROUTE 65 FROM KE
RECIPIENT(S): Jake.Garcia@dot.ca.gov;nathan.strid@dot.ca.gov
CONTRACTOR:
Global Road Sealing Inc

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