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:2021-07-20-4
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 1/8" x 7 1/2" A325 fasteners with Nuts and washers
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
Bay Bolt

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Bay Bolt
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/20/2021
BY: Greg Thompson
TITLE:
Assoc Steel Inspector (510-376-7155 cell)
DIST, CO, RTE, PM:
04-SF-80-R5.6/7.6
CONT. NO.: DEA: 043G4424
FED. NO.:
LIMITS:
SFOBB WEST SPAN
RECIPIENT(S): thomas.greg.thompson@dot.ca.gov;jason.m.gramlick@dot.ca.gov;rommoney.wu@dot.ca.gov;thomas.larwin@dot.ca.gov;sergio.gomez@dot.ca.gov;waqas.ather@dot.ca.gov
CONTRACTOR:
CALIFORNIA ENGINEERING CONTRACTORS, INC.

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