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: 2016-07-13-11
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:
Double Barrel Zap Screwlok
FOR USE IN:
SAMPLE FROM:
Job Site

DEPTH:
LOCATION OF SOURCE:
Barsplice Arceiormittal Nucor

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Barsplice Arceiormittal Nucor
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/13/2016
BY: Sarah Hartz
TITLE:
Unknown (Unknown)
DIST, CO, RTE, PM:
07-LA-18-0.2
CONT. NO.: DEA: 07274804
FED. NO.:
LIMITS:
LOS ANGELES COUNTY AT LLANO AT COUNTY LINE OVERHEA
RECIPIENT(S): rquan@altavistasolutions.com
CONTRACTOR:
MCM Construction - Cliff Dawley

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