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:2021-07-08-6
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:
All Thread Rod
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
Universal Industrial Sales Inc

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Universal Industrial Sales Inc
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/08/2021
BY: David Lund
TITLE:
CT METS QA INSPECTOR (385-447-0624)
DIST, CO, RTE, PM:
10-SJ-99-16.8/17.6
CONT. NO.: DEA: 100X3104
FED. NO.:
LIMITS:
SAN JOAQUIN COUNTY IN STOCKTON FROM 0.4 MILE SOUTH
RECIPIENT(S): david.lund@dot.ca.gov;jason.m.gramlick@dot.ca.gov;david.abledu@dot.ca.gov;daniel.laureno@dot.ca.gov;rajalingham.valluvan@dot.ca.gov
CONTRACTOR:
BRIDGEWAY CIVIL CONSTRUCTORS, INC.

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