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:2021-07-16-21
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:
1" and 5/8" A325 HDG fastener assemblies
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
CK Johnson Industries

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
CK Johnson Industries
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/16/2021
BY: Greg Thompson
TITLE:
Associate Steel Inspector (510-376-7155)
DIST, CO, RTE, PM:
01-HUM-101-R17.9/87.8
CONT. NO.: DEA: 010E7704
FED. NO.:
LIMITS:
HUMBOLDT COUNTY AT SOUTH FORK EEL RIVER AND SEPARA
RECIPIENT(S): jason.m.gramlick@dot.ca.gov;thomas.greg.thompson@dot.ca.gov;Joaquin.s.rodriguez@dot.ca.gov;Kari.Forbes@dot.ca.gov;peter.gan@dot.ca.gov
CONTRACTOR:
Freyssinet Inc

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