Sample Taken Date	06/07/2022	Sample Unique Key	62
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	06/16/2022
Sample type	Department Acceptance	A brief description of the sample	1 x 4 PCC Aggregate and Sand
The quantity of what the sample constitutes	300 CYS	From where was the sample collected	Fabricator
First name of sampler or witnessed by	Gerry	Last name of sampler or witnessed by	Zubieta
Title of sampler	TRANSPORTATION ENGINEER CIVIL	Telephone number of sampler
Laboratory sample identification	6849	Linked DIME Sample ID
The fabricator/manufacturer/facility name	Flat Iron Portable @ 210 & Paxton	Transportation Laboratory (TL) Number	924175
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)	91-19-0023
The fabricator's/manufacturer's product name for the sample	JPCP	The fabricator/manufacturer designation for the sample	Portable Plant
The plant number		A detailed description of where the material sample was collected	Conveyor Belt feeding weight hopper at the Plant
Where the material sample would have been placed if not sampled	PCC SLAB	Primary Aggregate Nominal Size	1 inch
The concrete mix design number	3215-06	Lot number
Sublot number		Aggregate Mix Number	Not set

DIME Test ID: 2022-06-07-62-1 CTM 202-November 2011 (Verified)
DIME Test ID: 2022-06-07-62-2 CTM 227-December 2014 (Verified)
DIME Test ID: 2022-06-07-62-3 CTM 202-November 2011 (Verified)
DIME Test ID: 2022-06-07-62-4 CTM 217-June 2011 (Verified)