Sample Identification Card TL-101

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STATE OF CALIFORNIA · DEPARTMENT OF TRANSPORTATION
SAMPLE IDENTIFICATION CARD
TL-0101 (REV. 10/12)

SAMPLE NUMBER:

TEST TYPE:

DIST. LAB
TRANS. LAB

SAMPLE SENT TO:

HDQRS. LAB
BRANCH LAB
DIST. LAB

FIELD NO.

DIST LAB NO.

LOT NO.

 

SHIPMENT NO.

P.O. OR REQ. NO.

 

AUTHORIZATION NO.

SAMPLE OF:
FOR USE IN:
SAMPLE FROM:
DEPTH:
LOCATION OF SOURCE:
THIS SAMPLE IS SHIPPED IN (NO. CONTAINERS)
AND IS ONE OF A GROUP OF
SAMPLES REPRESENTING (TONS, GALS, BBLS, STA, ETC.)
OWNER OR MANUFACTURER:
TOTAL QUANTITY AVAILABLE
TEST RESULTS DESIRED

NORMAL
PRIORITY

DATE NEEDED
REMARKS:
DATE SAMPLE:
BY:
TITLE:
DIST, CO, RTE, PM:
LIMITS:
CONT. NO.:
FED. NO.:
RECIPIENT(S):
CONTRACTOR:
© 2021 by California Department of Transportation (Caltrans)