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: 2021-08-11-1
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:
PSUE 1/2" HMA-A-SP R25, 0.8% Dry Lime
FOR USE IN:
Asphalt Paving
SAMPLE FROM:
Belt Cut at Granite Big Rock Plant

DEPTH:
LOCATION OF SOURCE:
91-19-0046::BIG ROCK CREEK- GRANITE

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-19-0046::BIG ROCK CREEK- GRANITE
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
08/11/2021
BY: William Lucas
TITLE:
DIST, CO, RTE, PM:
09-KER-14-R4.7/R12.6
CONT. NO.: DEA: 09367404
FED. NO.:
LIMITS:
KERN COUNTY AT AND NEAR ROSAMOND AND MOJAVE FROM 1
RECIPIENT(S): (to be selected by data publishing engineer)
CONTRACTOR:

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