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: 2015-10-19-11
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:
Three eighths 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
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):
CONTRACTOR:
C. A. Rasmussen, Inc.

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