Sample Taken Date	06/11/2021	Sample Unique Key	22
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	06/12/2021
Sample type	Quality Control	A brief description of the sample	Portland Cement Concrete
The quantity of what the sample constitutes	100 CY	From where was the sample collected	Job Site
First name of sampler or witnessed by	Michael	Last name of sampler or witnessed by	Thomas
Title of sampler		Telephone number of sampler
Laboratory sample identification		Linked DIME Sample ID
The fabricator/manufacturer/facility name	Hansen Bros Enterprises	Transportation Laboratory (TL) Number
Inspector Lot Number from the Transportation Laboratory (TL) Form		Structure unique identifier
Structure name

Material Type	Concrete	The concrete mix design number	8025P-WDNA
The truck number from where the sample was collected		The batch plant ticket number from where the sample was collected	05-195724
Concrete batch plant		The fabricator/manufacturer designation for the sample
A detailed description of where the material sample was collected	LOCATION 3 - BENT 7	Where the material sample would have been placed if not sampled
From Lot No.		Bag Lot No.

DIME Test ID: 2021-06-11-22-1 ASTM C143-20 (Verified)
DIME Test ID: 2021-06-11-22-2 CTM 557-June 2020 (Verified)
DIME Test ID: 2021-06-11-22-3 CTM 504-June 2010 (Verified)
DIME Test ID: 2021-06-11-22-4 CTM 518-June 2010 (Verified)