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: 2021-06-29-8
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:
#8 x 7'-0" dia.
FOR USE IN:
SAMPLE FROM:
Fabricator
DEPTH:
LOCATION OF SOURCE:
RKR Steel Welding
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
RKR Steel Welding
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
06/29/2021
BY:
Osiel Ramirez
TITLE:
DIST, CO, RTE, PM:
12-ORA-5-17.1/18.9
CONT. NO.:
DEA: 120K0234
FED. NO.:
LIMITS:
ORANGE COUNTY IN MISSION VIEJO, LAGUNA HILLS, LAGU
RECIPIENT(S):
Osiel.Ramirez@dot.ca.gov;LA.METS.Reports@dot.ca.gov;majid.javaherneshan@dot.ca.gov;young.j.kim@dot.ca.gov;venkatesh.iyer@dot.ca.gov
CONTRACTOR:
GUY F. ATKINSON CONSTRUCTION, LLC
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