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:2021-06-03-19
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:
Treated 3/8-inch Type A HMA (eq. PG 64-28 M) with 25.0% RAP and virgin PG 58-34 M from Valero – Benicia
FOR USE IN:
SAMPLE FROM:
Job Site

DEPTH:
LOCATION OF SOURCE:
JF Shea Construction - Fawndale Rock and Asphalt - Redding, CA

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
JF Shea Construction - Fawndale Rock and Asphalt - Redding, CA
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
06/03/2021
BY: Danny Hansen
TITLE:
Consultant ()
DIST, CO, RTE, PM:
02-SIS-89-14.0/19.0
CONT. NO.: DEA: 021J4504
FED. NO.:
LIMITS:
SISKIYOU COUNTY ABOUT 6 MILES NORTH OF BARTLE FROM
RECIPIENT(S): Austin.Henry@dot.ca.gov
CONTRACTOR:
S.T. Rhoades Construction

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