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:2021-04-20-3
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:
#6 1-6 1/2" Ø Welded Hoops Lot 10
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
TNT Rebar

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
TNT Rebar
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
04/20/2021
BY: Rigoberto Marin
TITLE:
QAI (951-500-0685)
DIST, CO, RTE, PM:
03-BUT-99-14.9/15.7
CONT. NO.: DEA: 030F2904
FED. NO.:
LIMITS:
BUTTE COUNTY ABOUT 10 MILES NORTH OF GRIDLEY FROM
RECIPIENT(S): LA.METS.Reports@dot.ca.gov;rigoberto.gutierrez.marin@dot.ca.gov;daniel.rechs@dot.ca.gov;anthony.english@dot.ca.gov;donald.adams@dot.ca.gov
CONTRACTOR:
A. TEICHERT & SON, INC. DBA TEICHERT CONSTRUCTION

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