Sample Identification Card TL-0101
You may optionally email a link to the detail page for this sample to project or other relevant personnel. For better printouts, please be sure to print the form using landscape orientation and 100% paper size.
STATE OF CALIFORNIA ● DEPARTMENT OF TRANSPORTATION
SAMPLE IDENTIFICATION CARD
TL-0101 (REV. 02/17)
DIME Sample ID: 2024-07-22-97
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:
16 boxes of Treated 1/2-inch Type A HMA with 15% RAP
FOR USE IN:
SAMPLE FROM:
Manufacturer
DEPTH:
LOCATION OF SOURCE:
Rocky Mnt Const.
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
Rocky Mnt Const.
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
07/22/2024
BY:
Dalton Esget
TITLE:
CGI Tech ()
DIST, CO, RTE, PM:
02-SIS-97,161-45.0/54.1,0.0/0.8
CONT. NO.:
DEA: 024H0004
FED. NO.:
LIMITS:
SISKIYOU COUNTY IN AND NEAR DORRIS ON ROUTE 97 FRO
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR:
To edit data on this form, you must be logged in to DIME and have sufficient privileges to edit the sample information.