Sample Taken Date	03/02/2020	Sample Unique Key	5
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	03/03/2020
Sample type	Acceptance	A brief description of the sample	Concrete beams
The quantity of what the sample constitutes	4 Beams	From where was the sample collected	Job Site
First name of sampler or witnessed by	QC	Last name of sampler or witnessed by	QC
Title of sampler		Telephone number of sampler
Laboratory sample identification	15A1, 15A2, 15B1, 15B2	Linked DIME Sample ID
The fabricator/manufacturer/facility name	Coffman Specialties, Inc	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	1810-2
The truck number from where the sample was collected	Unknown	The batch plant ticket number from where the sample was collected	TT1
Concrete batch plant	Unknown	The fabricator/manufacturer designation for the sample	Unknown
A detailed description of where the material sample was collected	On Job Site at Concrete Truck	Where the material sample would have been placed if not sampled	Unknown
From Lot No.	Unknown	Bag Lot No.	Unknown

DIME Test ID: 2020-03-02-5-1 CTM 523-July 2012 (Verified)
DIME Test ID: 2020-03-02-5-2 CTM 523-July 2012 (Verified)
DIME Test ID: 2020-03-02-5-3 CTM 523-July 2012 (Verified)
DIME Test ID: 2020-03-02-5-4 CTM 523-July 2012 (Verified)