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: 2021-10-10-2
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:
Course aggregate
FOR USE IN:
SAMPLE FROM:
Stockpile at the Plant

DEPTH:
LOCATION OF SOURCE:
91-34-0045::ASPEN IV SOUTH

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-34-0045::ASPEN IV SOUTH
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
10/10/2021
BY: Mike Kocunik
TITLE:
Lab Manager ()
DIST, CO, RTE, PM:
04-ALA-84,680-17.9/21
CONT. NO.: DEA: 04297634
FED. NO.:
LIMITS:
ALAMEDA COUNTY IN AND NEAR SUNOL, PLEASANTON, AND
RECIPIENT(S):
CONTRACTOR:
Bay Cities Paving & Grading

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