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:2021-06-10-1
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:
A706 Grade 60 #6 Welded Hoop
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
TNT Rebar Corp

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 Corp
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
06/10/2021
BY: Arthur Peterson
TITLE:
QA Inspector (7073428602)
DIST, CO, RTE, PM:
02-TRI-3-58.7/61.9
CONT. NO.: DEA: 024F2204
FED. NO.:
LIMITS:
TRINITY COUNTY NEAR TRINITY CENTER FROM 58.7 MILES
RECIPIENT(S): LA.METS.Reports@dot.ca.gov;arthur.peterson@dot.ca.gov;brian.h.thompson@dot.ca.gov
CONTRACTOR:
MCCULLOUGH CONSTRUCTION INC

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