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: 2021-06-10-28
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:
Combined Lime Treated Virgin 3/4-inch Type A Aggregate from cold feed at 150 tons
FOR USE IN:
SAMPLE FROM:
Cold Feed Sampling Device at Plant
DEPTH:
LOCATION OF SOURCE:
91-45-0017
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-45-0017
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
06/10/2021
BY:
Derrick Curry
TITLE:
CGI ()
DIST, CO, RTE, PM:
02-SIS,SIS-5-Var
CONT. NO.:
DEA: 024G41U4
FED. NO.:
LIMITS:
SHASTA AND SISKIYOU COUNTIES ABOUT 7 MILES NORTH O
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
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