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:2021-06-09-17
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:
10K Milestone, : RHMA-G-SP % LAS
FOR USE IN:
Asphalt Paving
SAMPLE FROM:
Belt Cut at Matich Cabazon

DEPTH:
LOCATION OF SOURCE:
91-33-0008, 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:
91-33-0008, 91-36-0040
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
06/09/2021
BY: Matich Cabazon QC
TITLE:
()
DIST, CO, RTE, PM:
08-RIV,SBD-62-R6.7/9.2,0.0/15.1,29.3/33.6
CONT. NO.: DEA: 081E8404
FED. NO.:
LIMITS:
IN RIVERSIDE AND SAN BERNARDINO COUNTIES IN AND NE
RECIPIENT(S):
CONTRACTOR:
Matich Corporation

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