Sample Taken Date	10/05/2022	Sample Unique Key	55
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	10/05/2022
Sample type	Quality Control	A brief description of the sample	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	Dylan	Last name of sampler or witnessed by	Bishop
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	7815-WSR6
The truck number from where the sample was collected		The batch plant ticket number from where the sample was collected	05-202220
Concrete batch plant		The fabricator/manufacturer designation for the sample
A detailed description of where the material sample was collected	Cisco grove bridge deck	Where the material sample would have been placed if not sampled
From Lot No.		Bag Lot No.

DIME Test ID: 2022-10-05-55-1 CTM 557-June 2020 (Verified)
DIME Test ID: 2022-10-05-55-2 CTM 504-June 2010 (Verified)
DIME Test ID: 2022-10-05-55-3 ASTM C143-20 (Verified)
DIME Test ID: 2022-10-05-55-4 CTM 521-June 2020 (Verified)