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:2021-08-10-21
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:
washed 3/8 inch
FOR USE IN:
(no information entered)
SAMPLE FROM:
silo

DEPTH:
LOCATION OF SOURCE:
SMARA 91 15 0041

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
SMARA 91 15 0041
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
08/10/2021
BY: Roberto Reyes
TITLE:
QC Technician ()
DIST, CO, RTE, PM:
12-ORA-5-17.1/18.9
CONT. NO.: DEA: 120K0234
FED. NO.:
LIMITS:
ORANGE COUNTY IN MISSION VIEJO, LAGUNA HILLS, LAGU
RECIPIENT(S):
CONTRACTOR:
GUY F. ATKINSON CONSTRUCTION, LLC

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