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:2021-08-20-8
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:
1-1/8x4-1/4 A325 HSB Assy - nut
FOR USE IN:
SAMPLE FROM:
Job Site

DEPTH:
LOCATION OF SOURCE:
LeJeune Bolt Company

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
LeJeune Bolt Company
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
08/20/2021
BY: Kevin Couch
TITLE:
smr (5304170632)
DIST, CO, RTE, PM:
04-CC-580-6.9/7.8
CONT. NO.: DEA: 042W1204
FED. NO.:
LIMITS:
Richmond San Rafael Bridge
RECIPIENT(S): jason.m.gramlick@dot.ca.gov;kevin.couch@dot.ca.gov;behzad.halali@dot.ca.gov;dylan.larose@dot.ca.gov
CONTRACTOR:
FLATIRON WEST INC

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