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: 2021-07-20-24
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:
PG 70-10
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
San Joaquin Refinery

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
San Joaquin Refinery
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/20/2021
BY: Rick Granite Tech
TITLE:
DIST, CO, RTE, PM:
06-FRE-198-26.3/26.8
CONT. NO.: DEA: 061A5304
FED. NO.:
LIMITS:
FRESNO COUNTY NEAR COALINGA FROM 0.5 MILE WEST OF
RECIPIENT(S): anourack.khampraseuth@dot.ca.gov;nathan.strid@dot.ca.gov
CONTRACTOR:
CALIFORNIA PROFESSIONAL ENGINEERING,INC.

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