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:2021-07-22-4
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:
#6 with A2 Lenton Couplers
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
C and N Reinforcing

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
C and N Reinforcing
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/22/2021
BY: Sherri Brannon
TITLE:
CA METS QA Inspector (916-826-6371)
DIST, CO, RTE, PM:
04-ALA-84-10.8/18
CONT. NO.: DEA: 042A3324
FED. NO.:
LIMITS:
ALAMEDA CREEK BR OH (33-0034) BRIDGE RAIL REPLACEM
RECIPIENT(S): sherri.brannon@dot.ca.gov;jason.m.gramlick@dot.ca.gov;davinder.singh@dot.ca.gov;jordan.jarosz@dot.ca.gov;dylan.larose@dot.ca.gov
CONTRACTOR:
Bay Cities Paving & Grading

To edit data on this form, you must be logged in to DIME and have sufficient privileges to edit the sample information.