Sample Taken Date	11/06/2024	Sample Unique Key	13
Will the laboratory/organization for which you are a member perform testing on this material sample?	Yes	Date that the sample was received by the laboratory/organization performing the testing	11/06/2024
Sample type	Acceptance	A brief description of the sample	Shoulder Backing Material
The quantity of what the sample constitutes	1Bags of Shoulder Backing	From where was the sample collected	Source
First name of sampler or witnessed by	Mike	Last name of sampler or witnessed by	Cozad
Title of sampler	Inspector	Telephone number of sampler
Laboratory sample identification		Linked DIME Sample ID
The fabricator/manufacturer/facility name	Griffith Edmonston	Transportation Laboratory (TL) Number
Inspector Lot Number from the Transportation Laboratory (TL) Form		Structure unique identifier
Structure name		Bid Item	Not set

Material Type	Aggregate	Source Identification (SMARA, name of Pit or Job Site)	91-15-0068
The fabricator's/manufacturer's product name for the sample		The fabricator/manufacturer designation for the sample
The plant number		A detailed description of where the material sample was collected	Shoulder Backing Machine
Where the material sample would have been placed if not sampled		Primary Aggregate Nominal Size	1 inch
The concrete mix design number		Lot number
Sublot number		Aggregate Mix Number

DIME Test ID: 2024-11-06-13-1 CTM 202-November 2011 (Verified)
DIME Test ID: 2024-11-06-13-2 CTM 217-June 2011 (Verified)
DIME Test ID: 2024-11-06-13-3 CTM 229-June 2011 (Verified)
DIME Test ID: 2024-11-06-13-4 CTM 226-July 2010 (Verified)