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: 2023-09-28-87
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 w/25% RAP
FOR USE IN:
SAMPLE FROM:
Plant Sampler

DEPTH:
LOCATION OF SOURCE:
91-01-0010

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-01-0010
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
09/28/2023
BY: Dennis Yeung
TITLE:
DIST, CO, RTE, PM:
04-ALA-84,680-17.9/21
CONT. NO.: DEA: 04297634
FED. NO.:
LIMITS:
ALAMEDA COUNTY IN AND NEAR SUNOL, PLEASANTON, AND
RECIPIENT(S): (to be selected by data publishing engineer)
CONTRACTOR:

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