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:2021-06-02-20
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:
Clean Sand and Gravel
FOR USE IN:
Unknown
SAMPLE FROM:
Stockpile at Aggregate Products

DEPTH:
LOCATION OF SOURCE:
91-45-0019

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-45-0019
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
06/02/2021
BY: Cindy Bryant
TITLE:
TET ()
DIST, CO, RTE, PM:
02-LAS,SHA,TEH-5,32,36,44,299-VAR
CONT. NO.: DEA: 024G5304
FED. NO.:
LIMITS:
LASSEN, SHASTA, AND TEHAMA COUNTIES AT VARIOUS LOC
RECIPIENT(S): Terrance.Schmitt@dot.ca.gov;tofael.anwar@dot.ca.gov
CONTRACTOR:
SERAFIX ENGINEERING CONTRACTORS, INC.

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