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: 2021-09-28-38
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:
BINDER
FOR USE IN:
SAMPLE FROM:
Source

DEPTH:
LOCATION OF SOURCE:
San Joaquin Refinery

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
San Joaquin Refinery
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
09/28/2021
BY: Unknown GRANITE Unknown GRANITE
TITLE:
DIST, CO, RTE, PM:
06-KER-155-35.5/37.5,42.5/44.5
CONT. NO.: DEA: 061B0204
FED. NO.:
LIMITS:
KERN COUNTY NEAR GLENVILLE FROM 3.3 MILES EAST OF
RECIPIENT(S): robert.decker.jr@dot.ca.gov;nathan.strid@dot.ca.gov
CONTRACTOR:
GRANITE CONSTRUCTION COMPANY

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