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: 2021-03-31-9
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:
PSUE 1/2" RHMA-G-SP, 1.0% LAS
FOR USE IN:
Asphalt Paving
SAMPLE FROM:
Belt Cut at All American Irwindale Plant
DEPTH:
LOCATION OF SOURCE:
91-33-0005
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-33-0005
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
03/31/2021
BY:
Gerardo Zubieta
TITLE:
DIST, CO, RTE, PM:
07-LA-60,710-710-R2.8/11.8, 24.1/25.1
CONT. NO.:
DEA: 07301104
FED. NO.:
LIMITS:
In Los Angeles County at avocado Heights on Route
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
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