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:2021-04-16-4
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:
1/2x3 1/2" A325 Hex Nut (HDG)
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
Universal Industrial Sales Inc

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Universal Industrial Sales Inc
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
04/16/2021
BY: David Lund
TITLE:
CT METS QA INSPECTOR (801-462-6352)
DIST, CO, RTE, PM:
05-SLO-101-3.5
CONT. NO.: DEA: 051J7604
FED. NO.:
LIMITS:
RECIPIENT(S): david.lund@dot.ca.gov;jason.m.gramlick@dot.ca.gov;lilian.Bennetzen@dot.ca.gov;Alex.Martinez@dot.ca.gov;kevin.couch@dot.ca.gov
CONTRACTOR:
SABU, LLC

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