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: 2021-06-02-19
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:
Native Subgrade
FOR USE IN:
02 LAS MOD 139 299 VAR
SAMPLE FROM:
02 LAS, MOD 139, 299 VAR EB A LINE at STA 1338 00 Adin Ca

DEPTH:
LOCATION OF SOURCE:
Unknown

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Unknown
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
06/02/2021
BY: E. Chavez
TITLE:
Unknown ()
DIST, CO, RTE, PM:
02-LAS,MOD-139,299-VAR
CONT. NO.: DEA: 024E4504
FED. NO.:
LIMITS:
LASSEN AND MODOC COUNTIES ON ROUTE 139 AT 0.1 MILE
RECIPIENT(S):
CONTRACTOR:
PAR ELECTRICAL CONTRACTORS INC

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