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: 2015-10-13-10
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:
Concrete aggregates 1 inch x No 4 coarse and sand
FOR USE IN:
Bridge Deck
SAMPLE FROM:
Belt cut of Coarse and Fine Aggregate at Source

DEPTH:
LOCATION OF SOURCE:
150180

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
150180
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
10/13/2015
BY: Mark Alexander
TITLE:
QC Technician (5106141044)
DIST, CO, RTE, PM:
04-SCL,SM-101-52.0/52.6,0.0/0.6
CONT. NO.: DEA: 04235624
FED. NO.:
LIMITS:
SANTA CLARA AND SAN MATEO COUNTIES IN PALO ALTO AN
RECIPIENT(S):
CONTRACTOR:
GHILOTTI BROS / RM HARRIS JV

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