Sample Identification Card TL-0101

You may optionally email a link to the detail page for this sample to project or other relevant personnel. For better printouts, please be sure to print the form using landscape orientation and 100% paper size.

×
STATE OF CALIFORNIA ● DEPARTMENT OF TRANSPORTATION
SAMPLE IDENTIFICATION CARD
TL-0101 (REV. 02/17)
DIME Sample ID:2021-08-13-23
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:
Embankment soil for shoulder construction
FOR USE IN:
02 LAS MOD 299 VAR
SAMPLE FROM:
02, LAS MOD, 299 Sta 1066 00 at EB A Line

DEPTH:
LOCATION OF SOURCE:
Unknown

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Unknown
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
08/13/2021
BY: E. Chavez
TITLE:
Materials Tester ()
DIST, CO, RTE, PM:
02-LAS,MOD-139,299-VAR
CONT. NO.: DEA: 024E4504
FED. NO.:
LIMITS:
LASSEN AND MODOC COUNTIES ON ROUTE 139 AT 0.1 MILE
RECIPIENT(S): mike.zdenek@dot.ca.gov
CONTRACTOR:
PAR ELECTRICAL CONTRACTORS INC

To edit data on this form, you must be logged in to DIME and have sufficient privileges to edit the sample information.