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:2021-07-29-26
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:
bearing pad
FOR USE IN:
SAMPLE FROM:
Manufacturer

DEPTH:
LOCATION OF SOURCE:
Dynamic Rubber

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Dynamic Rubber
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/29/2021
BY: Kayla Wallace
TITLE:
()
DIST, CO, RTE, PM:
04-SOL-29,80-0.0,0.8/1.6
CONT. NO.: DEA: 042K8404
FED. NO.:
LIMITS:
SOLANO COUNTY IN VALLEJO AT ROUTE 80/29 SEPARATION
RECIPIENT(S): noel.aquino@dot.ca.gov;angelo.perez@dot.ca.gov;dylan.larose@dot.ca.gov
CONTRACTOR:
OC Jones & Sons Inc

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