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: 2022-05-04-26
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:
EMULSION
FOR USE IN:
SAMPLE FROM:
Other

DEPTH:
LOCATION OF SOURCE:
TALLY OIL INC

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
TALLY OIL INC
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
05/04/2022
BY: TALLY OIL INC
TITLE:
QC ()
DIST, CO, RTE, PM:
06-KER-223-R10.6/R20.1
CONT. NO.: DEA: 061C4604
FED. NO.:
LIMITS:
KERN COUNTY NEAR ARVIN FROM ROUTE 223/99 SEPARATIO
RECIPIENT(S): Amarjit.dhaliwal@dot.ca.gov;nathan.strid@dot.ca.gov
CONTRACTOR:
AMERICAN PAVEMENT SYSTEMS , Inc.

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