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: 2022-04-11-1
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" all Thread Bar
FOR USE IN:
SAMPLE FROM:
Supplier

DEPTH:
LOCATION OF SOURCE:
Williams Form Eng

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Williams Form Eng
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
04/11/2022
BY: Lorenzo Garcia
TITLE:
QA (17029172503)
DIST, CO, RTE, PM:
02-TEH-5-R25.4
CONT. NO.: DEA: 024F5904
FED. NO.:
LIMITS:
TEHAMA COUNTY IN RED BLUFF AT SACRAMENTO RIVER BRI
RECIPIENT(S): LA.METS.Reports@dot.ca.gov;lorenzo.garcia@dot.ca.gov;mike.zdenek@dot.ca.gov;ryan.duran@dot.ca.gov;brian.h.thompson@dot.ca.gov
CONTRACTOR:
Golden State Bridge

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