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: 2021-06-22-32
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:
PG64-28M
FOR USE IN:
SAMPLE FROM:
Manufacturer
DEPTH:
LOCATION OF SOURCE:
na
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
na
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
06/22/2021
BY:
M Cozad
TITLE:
DIST, CO, RTE, PM:
10-MER-140-37.4/44.8
CONT. NO.:
DEA: 101J1904
FED. NO.:
LIMITS:
MERCED COUNTY IN AND NEAR MERCED FROM SANTA FE AVE
RECIPIENT(S):
muhammad.rahman@dot.ca.gov;rajalingham.valluvan@dot.ca.gov
CONTRACTOR:
GEORGE REED , INC.
To edit data on this form, you must be logged in to DIME and have sufficient privileges to edit the sample information.