Sample Taken Date	01/30/2023	Sample Unique Key	53
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	02/16/2023
Sample type	Aggregate Prequalification Program	A brief description of the sample	1" X # 4 Concrete Aggregate
The quantity of what the sample constitutes	production stockpile.	From where was the sample collected	Supplier
First name of sampler or witnessed by	Trenton	Last name of sampler or witnessed by	Crouse
Title of sampler	Supervisor	Telephone number of sampler	916-607-9151
Laboratory sample identification	23-APPC-0018	Linked DIME Sample ID	2023-01-30-35
The fabricator/manufacturer/facility name	Teichert Hallwood	Transportation Laboratory (TL) Number
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)	91-58-0006
The fabricator's/manufacturer's product name for the sample		The fabricator/manufacturer designation for the sample
The plant number		A detailed description of where the material sample was collected	Teichert Hallwood plant site stockpile
Where the material sample would have been placed if not sampled		Primary Aggregate Nominal Size	1 inch
The concrete mix design number		Lot number
Sublot number		Aggregate Mix Number

DIME Test ID: 2023-01-30-53-1 CTM 202-November 2011 (Verified)
DIME Test ID: 2023-01-30-53-2 CTM 227-December 2014 (Verified)
DIME Test ID: 2023-01-30-53-3 CTM 211-May 2010 (Verified)
DIME Test ID: 2023-01-30-53-4 CTM 214-August 2010 (Verified)