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:2021-04-22-26
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:
3/8" PCC Aggregate
FOR USE IN:
(no information entered)
SAMPLE FROM:
Stockpile @ Plant

DEPTH:
LOCATION OF SOURCE:
91-36-0040

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-36-0040
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
04/22/2021
BY: Marc Segura
TITLE:
QC Representative ()
DIST, CO, RTE, PM:
59---
CONT. NO.: DEA: APP
FED. NO.:
LIMITS:
RECIPIENT(S): APP.Admin@dot.ca.gov;ali.tadjalli@dot.ca.gov;albertm.segura@cemex.com;Nader.rashidi@dot.ca.gov
CONTRACTOR:

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