Print Blank TL-101



STATE OF CALIFORNIA ● DEPARTMENT OF TRANSPORTATION
SAMPLE IDENTIFICATION CARD
TL-0101 (REV. 10/12)
SAMPLE NUMBER:
FIELD NO.

DIST LAB NO.

LOT NO.

P.O. OR REQ. NO.

SAMPLE SENT TO:
HDQRS. LAB
BRANCH LAB
DIST. LAB
SHIPMENT NO.

AUTHORIZATION NO.
TEST TYPE:
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
TOTAL QUANTITY AVAILABLE
REMARKS:
DATE SAMPLE:
BY:
TITLE:
DIST, CO, RTE, PM:
LIMITS:
CONT. NO.:
FED. NO.:
RECIPIENT(S):
CONTRACTOR:
©DIME 2016