Sample Identification Card TL-0101
You may optionally email a link to the detail page for this sample to project or other relevant personnel. For better printouts, please be sure to print the form using landscape orientation and 100% paper size.
STATE OF CALIFORNIA ● DEPARTMENT OF TRANSPORTATION
SAMPLE IDENTIFICATION CARD
TL-0101 (REV. 02/17)
DIME Sample ID: 2021-06-02-23
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
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
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
06/02/2021
BY:
RANDY UNKNOWN
TITLE:
CGI ()
DIST, CO, RTE, PM:
02-SIS-89-14.0/19.0
CONT. NO.:
DEA: 021J4504
FED. NO.:
LIMITS:
SISKIYOU COUNTY ABOUT 6 MILES NORTH OF BARTLE FROM
RECIPIENT(S):
nicole.mallory@dot.ca.gov;brian.h.thompson@dot.ca.gov;Austin.Henry@dot.ca.gov
CONTRACTOR:
S.T. Rhoades Construction
To edit data on this form, you must be logged in to DIME and have sufficient privileges to edit the sample information.