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: 2022-09-02-78
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:
aggregate
FOR USE IN:
SAMPLE FROM:
From stockpiles at source

DEPTH:
LOCATION OF SOURCE:
Shamrock Materials Petaluma

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Shamrock Materials Petaluma
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
09/02/2022
BY: Shamrock Petaluma
TITLE:
batch plant (707-765-8560)
DIST, CO, RTE, PM:
04-MRN-101-R20.8/27.1
CONT. NO.: DEA: 04264724
FED. NO.:
LIMITS:
MARIN COUNTY IN AND NEAR NOVATO FROM 0.1 MILE SOUT
RECIPIENT(S): (to be selected by data publishing engineer)
CONTRACTOR:

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