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: 2023-11-08-2
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:
A325 Fastener Assemblies
FOR USE IN:
SAMPLE FROM:
Fabricator
DEPTH:
LOCATION OF SOURCE:
Cordova Bolt Inc. Buena Park, CA.
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Cordova Bolt Inc. Buena Park, CA.
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
11/08/2023
BY:
Henry Arredondo
TITLE:
CALTRANS METS QA INSPECTOR (5623329603)
DIST, CO, RTE, PM:
12-ORA-5,133,241-122,241-var
CONT. NO.:
DEA: 120Q9304
FED. NO.:
LIMITS:
ORANGE COUNTY AT VARIOUS LOCATIONS
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
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