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: 2015-10-19-9
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:
One and a half inch PCC Aggregates
FOR USE IN:
Unknown
SAMPLE FROM:
Plant Stockpiles
DEPTH:
LOCATION OF SOURCE:
SMARA 91 33 0008
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
SMARA 91 33 0008
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
10/19/2015
BY:
Tom Milum
TITLE:
QC Technician (Unknown)
DIST, CO, RTE, PM:
07-LA-I-110,JohnS.GibsonBlvd-I-110 PM 0.92/2.02 & SR 47 PM 0.0/0.72.
CONT. NO.:
DEA: 07260604
FED. NO.:
LIMITS:
John S. Gibson Blvd/I-110 Fwy & SR-47/I-110
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
To edit data on this form, you must be logged in to DIME and have sufficient privileges to edit the sample information.