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:2021-05-06-28
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:
3/4-inch Type A HMA (eq. PG 64-28 M)
FOR USE IN:
SAMPLE FROM:
Manufacturer

DEPTH:
LOCATION OF SOURCE:
Knife River Construction - Orland 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:
Knife River Construction - Orland Plant
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
05/06/2021
BY: Cindy Bryant
TITLE:
()
DIST, CO, RTE, PM:
02-TRI-36-R34.8/R35.4
CONT. NO.: DEA: 022H0504
FED. NO.:
LIMITS:
TRINITY COUNTY ABOUT 15 MILES WEST OF PLATINA FROM
RECIPIENT(S): joel.gasik@dot.ca.gov
CONTRACTOR:
STEVE MANNING CONSTRUCTION, INC

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