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:2021-07-14-38
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:
PG64-10
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
JF Shea - Fawndale

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
JF Shea - Fawndale
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/14/2021
BY: C Bryant
TITLE:
TET ()
DIST, CO, RTE, PM:
02-SHA-5-R3.8/R11.7
CONT. NO.: DEA: 024C40V4
FED. NO.:
LIMITS:
SHASTA COUNTY IN AND NEAR ANDERSON FROM ROUTE 5/27
RECIPIENT(S): henry.benner@dot.ca.gov;brian.h.thompson@dot.ca.gov
CONTRACTOR:
J.F. SHEA CONSTRUCTION

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