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: 2021-06-18-29
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:
2 pints 204, chp, z cure, 8020
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
Kwik Bond Polymers, 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:
Kwik Bond Polymers, Benicia
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
06/18/2021
BY: Daniel Tikusis
TITLE:
DIST, CO, RTE, PM:
12-ORA-22,57-R2.7/R11.9,18.8
CONT. NO.: DEA: 120S2004
FED. NO.:
LIMITS:
ORANGE COUNTY AT VARIOUS LOCATIONS ON ROUTE 22 FRO
RECIPIENT(S): (to be selected by data publishing engineer)
CONTRACTOR:

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