Sample Taken Date	12/09/2021	Sample Unique Key	12
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	01/20/2022
Sample type	Verification	A brief description of the sample	Asphalt Binder
The quantity of what the sample constitutes	2 of 2, split sample	From where was the sample collected	Manufacturer
First name of sampler or witnessed by	Elena	Last name of sampler or witnessed by	Hubert
Title of sampler	COC Program	Telephone number of sampler
Laboratory sample identification		Linked DIME Sample ID	2021-12-09-9
The fabricator/manufacturer/facility name	Western Emulsion White City	Transportation Laboratory (TL) Number
Inspector Lot Number from the Transportation Laboratory (TL) Form		Structure unique identifier
Structure name		Bid Item	Not set

Material Type	Asphalt Binder	Performance Grade	PG 58-22
Modified	No	Lot number
Sublot number		Tank number
Time of sample	0800	HMA Supplier
Certified Asphalt Supplier	Western Emulsion - White City Emulsion Plant - White City OR	Multigrade	No
Multigrade Type		Asphalt Binder Mix Number	Not set

DIME Test ID: 2021-12-09-12-2 AASHTO T315-20 (Verified)
DIME Test ID: 2021-12-09-12-3 AASHTO T315-20 (Verified)
DIME Test ID: 2021-12-09-12-4 AASHTO T315-20 (Verified)
DIME Test ID: 2021-12-09-12-5 AASHTO T313-19 (Verified)