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: 2023-10-19-41
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" RHMA-G
FOR USE IN:
HWY 1 Pismo Beach
SAMPLE FROM:
Belt Discharge
DEPTH:
LOCATION OF SOURCE:
91-42-0014
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
91-42-0014
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
10/19/2023
BY:
Isaac Gleffe
TITLE:
ARET (18053191237)
DIST, CO, RTE, PM:
05-SLO-1-10.0/16.8
CONT. NO.:
DEA: 051G9804
FED. NO.:
LIMITS:
SAN LUIS OBISPO COUNTY FROM GRACIA WAY AT OCEANO T
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
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