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:2021-08-20-14
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 gallon can
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
Kwik Bond Polymers and Polynt

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Kwik Bond Polymers and Polynt
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
08/20/2021
BY: Daniel Tikusis
TITLE:
Technical Director (707-330-9227)
DIST, CO, RTE, PM:
02-SIS-5-R8.3
CONT. NO.: DEA: 021H4004
FED. NO.:
LIMITS:
SISKIYOU COUNTY NEAR MOUNT SHASTA AT AZALEA ROAD O
RECIPIENT(S): brian.h.thompson@dot.ca.gov
CONTRACTOR:
Abacus Construction, Inc.

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