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:2021-05-21-7
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:
Superior D101 Form Savers
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
PJs 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:
PJs Rebar
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
05/21/2021
BY: Sherri Brannon
TITLE:
QA Inspector (916-826-6371)
DIST, CO, RTE, PM:
01-DN-101-8.2/8.7
CONT. NO.: DEA: 010B0904
FED. NO.:
LIMITS:
DEL NORTE COUNTY NEAR KLAMATH AT PANTHER CREEK BRI
RECIPIENT(S): sherri.brannon@dot.ca.gov;jason.m.gramlick@dot.ca.gov;robert.pekrul@dot.ca.gov;clayton.malmberg@dot.ca.gov;bryan.keene@dot.ca.gov;peter.gan@dot.ca.gov
CONTRACTOR:
Golden State Bridge, Inc

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