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: 2021-05-24-38
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:
ASPHALT BINDER
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
Valero-Benicia Asphalt Plant

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Valero-Benicia Asphalt Plant
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
05/24/2021
BY: D. OWENS
TITLE:
PEI ()
DIST, CO, RTE, PM:
02-SHA,TRI-36-8.0/11.912,27.1/R41.139
CONT. NO.: DEA: 021J4804
FED. NO.:
LIMITS:
SHASTA AND TRINITY COUNTIES AT AND NEAR PLATINA FR
RECIPIENT(S): nathan.alexander@dot.ca.gov;brian.h.thompson@dot.ca.gov
CONTRACTOR:
NORTHWEST PAVING, INC

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