Print SMTL Report
State of California
Department of Transportation
Structural Materials Testing
Laboratory
5900 Folsom Boulevard, Sacramento,CA
95819
TEST REPORT
Sample No:
______________________________
Date Received:
Date Sampled:
__________
Date Reported:
Sampler:
________________
Inspector Lot No:
N/A
TL-101/SIC No:
N/A
Contract/Permit No:
___________
Material:
______________________________
Manufacturer:
______________________________
Note:
Results apply to the sample as received and items tested.
Test reports shall only be reproduced for Caltrans administered projects.
Reviewed by:
Approved by:
_____________________
Josh Moore
Lab Manager
SMTL Quality Manager
STATE OF CALIFORNIA ● DEPARTMENT OF TRANSPORTATION
SAMPLE IDENTIFICATION CARD
TL-0101 (REV. 02/17)
DIME Sample ID:
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:
FOR USE IN:
SAMPLE FROM:
DEPTH:
LOCATION OF SOURCE:
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
AND IS ONE OF A GROUP OF
THIS SAMPLE IS SHIPPED IN(NO. CONTAINERS)
OWNER OR MANUFACTURER:
DATE NEEDED
TEST RESULTS DESIRED
NORMAL PRIORITY
NORMAL PRIORITY
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLED:
BY:
TITLE:
DIST, CO, RTE, PM:
CONT. NO.:
FED. NO.:
LIMITS:
RECIPIENT(S):
(to be selected by data publishing engineer)
CONTRACTOR: