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:2021-03-11-14
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:
Rapid Setting Concrete
FOR USE IN:
SAMPLE FROM:
Manufacturer

DEPTH:
LOCATION OF SOURCE:
Sika Corporation

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Sika Corporation
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
03/11/2021
BY: Thao Vu
TITLE:
QC Specialist ()
DIST, CO, RTE, PM:
03-BUT,COL,GLE,SUT,YOL-5,32,70,80,162-VAR
CONT. NO.: DEA: 031G5104
FED. NO.:
LIMITS:
BUTTE, COLUSA, GLENN, SUTTER, AND YOLO COUNTIES AT
RECIPIENT(S):
CONTRACTOR:
TRUESDELL CORP OF CALIFORNIA INC

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