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:2016-12-02-3
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:
A536 Ductile Iron
FOR USE IN:
SAMPLE FROM:
Fabricator

DEPTH:
LOCATION OF SOURCE:
DSI Dotson Iron

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
DSI Dotson Iron
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
12/02/2016
BY: Debbie Ozuna
TITLE:
Unknown (Unknown)
DIST, CO, RTE, PM:
08-SBD-15-171.8/173.8
CONT. NO.: DEA: 080M2804
FED. NO.:
LIMITS:
In SBD County
RECIPIENT(S): LA.METS.Reports@dot.ca.gov;john.santos@dot.ca.gov;fzahlout@syrusaengineering.com;bdagher@altavistasolutions.com
CONTRACTOR:
M.C.M. CONSTRUCTION, INC. - Dan Shaw

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