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:   ___________
TL-101/SIC No:
N/A
Contract/Permit No:
___________
Material:  
______________________________
Manufacturer:   
______________________________
Note:   Results relate only to the items tested. Test reports shall only be reproduced for Caltrans administered projects.
Reviewed by:   Approved by:  _____________________
Paul Lukkarila
Lab ManagerSMTL 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:
SAMPLE FROM:
FOR USE IN:
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
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLE:
BY:
TITLE:
()
DIST, CO, RTE, PM:
CONT. NO.:
FED. NO.:
LIMITS:
RECIPIENT(S): (to be selected by data publishing engineer)
CONTRACTOR: