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: 2022-03-18-10
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:
#8 HRC 120 T Heads
FOR USE IN:
SAMPLE FROM:
Manufacturer

DEPTH:
LOCATION OF SOURCE:
Headed Reinforcement Corp, Fountain Valley, CA

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Headed Reinforcement Corp, Fountain Valley, CA
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
03/18/2022
BY: Brian Murray
TITLE:
QA Inspector (213 435 4055)
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): brian.murray@dot.ca.gov;LA.METS.Reports@dot.ca.gov;mohamed.kaddoura@hdrinc.com;dylan.larose@dot.ca.gov
CONTRACTOR:
Bay Cities Paving & Grading

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