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: 2021-06-18-28
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:
#11 HRC 500/510 Couplers
FOR USE IN:
SAMPLE FROM:
Job Site

DEPTH:
LOCATION OF SOURCE:
CMC

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
CMC
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
06/18/2021
BY: Zachary Chao
TITLE:
ASR ()
DIST, CO, RTE, PM:
03-PLA-80-2.6/3.1
CONT. NO.: DEA: 030H4604
FED. NO.:
LIMITS:
PLACER COUNTY IN ROSEVILLE AT THE ATLANTIC STREET
RECIPIENT(S): crl.c.anderson@dot.ca.gov;Justin.Kunert@dot.ca.gov;carl.c.anderson@dot.ca.gov;donald.adams@dot.ca.gov
CONTRACTOR:
Myers & Sons Construction

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