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:2021-07-13-24
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:
TEST Asphalt Binder
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
Valero - Benicia

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Valero - Benicia
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/13/2021
BY: P Dolby
TITLE:
TET ()
DIST, CO, RTE, PM:
01-LAK-175-0.2/0.4
CONT. NO.: DEA: 010H4604
FED. NO.:
LIMITS:
LAKE COUNTY ABOUT 10 MILES EAST OF HOPLAND FROM 0.
RECIPIENT(S): dan.kraft@dot.ca.gov;peter.gan@dot.ca.gov
CONTRACTOR:
GRANITE CONSTRUCTION COMPANY

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