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:2016-12-07-6
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:
Bar Lock Couplers
FOR USE IN:
SAMPLE FROM:
Job Site

DEPTH:
LOCATION OF SOURCE:
Gerdau Dayton Superior

SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Gerdau Dayton Superior
DATE NEEDED
TEST RESULTS DESIRED
NORMAL   PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
12/07/2016
BY: Jose Baal
TITLE:
Unknown (Unknown)
DIST, CO, RTE, PM:
05-SLO-46-46.0/50.2
CONT. NO.: DEA: 05330784
FED. NO.:
LIMITS:
NEAR SHANDON FROM 0.2 MILE EAST OF MCMILLIAN CANYO
RECIPIENT(S): karl.mikel@dot.ca.gov;nicholas.heisdorf@dot.ca.gov;bkrol@altavistasolutions.com
CONTRACTOR:
BROSAMER & WALL, INC.

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