Sample Taken Date	06/21/2022	Sample Unique Key	49
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	06/24/2022
Sample type	Department Acceptance	A brief description of the sample	6X12 PCC cylinder
The quantity of what the sample constitutes	130 CY	From where was the sample collected	Job Site
First name of sampler or witnessed by	David	Last name of sampler or witnessed by	Bar-On
Title of sampler	Assistant Structure Representative	Telephone number of sampler
Laboratory sample identification	22-0164	Linked DIME Sample ID
The fabricator/manufacturer/facility name	Holiday Rock	Transportation Laboratory (TL) Number	NA
Inspector Lot Number from the Transportation Laboratory (TL) Form		Structure unique identifier
Structure name		Bid Item	Not set

Material Type	Concrete	The concrete mix design number	3C50L001
The truck number from where the sample was collected		The batch plant ticket number from where the sample was collected	NA
Concrete batch plant		The fabricator/manufacturer designation for the sample
A detailed description of where the material sample was collected	truck chute	Where the material sample would have been placed if not sampled
From Lot No.		Bag Lot No.

DIME Test ID: 2022-06-21-49-1 CTM 521-June 2020 (Verified)
DIME Test ID: 2022-06-21-49-2 CTM 521-June 2020
DIME Test ID: 2022-06-21-49-3 CTM 521-June 2020 (Verified)
DIME Test ID: 2022-06-21-49-4 CTM 521-June 2020 (Verified)