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: 2023-04-05-55
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:
3/4 hma core
FOR USE IN:
SAMPLE FROM:
Job Site

DEPTH:
LOCATION OF SOURCE:
Las Vegs Paving Company-Las Vegas

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Las Vegs Paving Company-Las Vegas
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
04/05/2023
BY: robert romero
TITLE:
QC ()
DIST, CO, RTE, PM:
08-SBD-10-0.0/13.2
CONT. NO.: DEA: 080C2514
FED. NO.:
LIMITS:
LA/SBD County Line to PM 13.2 near I-15
RECIPIENT(S): william.clifford@dot.ca.gov;kaushalkumar.talati@dot.ca.gov;vicente.bunyi@dot.ca.gov;ryan.cummings@dot.ca.gov;frederic.aboujaoude@dot.ca.gov;esantamaria@g3quality.com;michael.cattabiani@dot.ca.gov;nicholas.hoffmann@dot.ca.gov;julius.esonwune@dot.ca.gov;LARRY.FRANCISCO@DOT.CA.GOV;avalencia@i-10express.com;kee.ooi@dot.ca.gov;skhalil@i-10express.com;fzahlout@syrusaengineering.com;scott.bauer@dot.ca.gov
CONTRACTOR:
Lane-Security Paving Joint Venture

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