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:2021-05-17-42
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 Treated Virgin Aggregate
FOR USE IN:
(no information entered)
SAMPLE FROM:
Cold Feed

DEPTH:
LOCATION OF SOURCE:
91-25-0008

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-25-0008
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
05/17/2021
BY: Emilio Chavez
TITLE:
()
DIST, CO, RTE, PM:
02-LAS,MOD-139,299-VAR
CONT. NO.: DEA: 024E4504
FED. NO.:
LIMITS:
LASSEN AND MODOC COUNTIES ON ROUTE 139 AT 0.1 MILE
RECIPIENT(S): mike.zdenek@dot.ca.gov
CONTRACTOR:
PAR ELECTRICAL CONTRACTORS INC

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