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:2014-07-08-17302745
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:
Class 3 Aggregate Base
FOR USE IN:
Unknown
SAMPLE FROM:
Shoulder

DEPTH:
LOCATION OF SOURCE:
Atlantic Yard Stockpile

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Atlantic Yard Stockpile
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/08/2014
BY: Ramsey Doumani
TITLE:
Materials Tester (Unknown)
DIST, CO, RTE, PM:
07-LA-710-17.2/26.4
CONT. NO.: DEA: 07202114
FED. NO.:
LIMITS:
LOS ANGELES COUNTY ON ROUTE 710 AT VARIOUS LOCATIO
RECIPIENT(S):
CONTRACTOR:
SHIMMICK/MYERS AND SONS JV

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