Sample Taken Date	10/28/2020	Sample Unique Key	13
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	10/29/2020
Sample type	Quality Assurance	A brief description of the sample	Hydrolite-Trinity Lightweight
The quantity of what the sample constitutes	3-5 gallon bucket	From where was the sample collected	Job Site
First name of sampler or witnessed by	not available	Last name of sampler or witnessed by	not available
Title of sampler		Telephone number of sampler
Laboratory sample identification	20-PCCC-0217	Linked DIME Sample ID
The fabricator/manufacturer/facility name	na	Transportation Laboratory (TL) Number	na
Inspector Lot Number from the Transportation Laboratory (TL) Form		Structure unique identifier
Structure name

Material Type	Aggregate	Source Identification (SMARA, name of Pit or Job Site)	na
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	at job site
Where the material sample would have been placed if not sampled		Primary Aggregate Nominal Size	3/8 inch
The concrete mix design number		Lot number
Sublot number		Aggregate Mix Number	Not set

DIME Test ID: 2020-10-28-13-2 CTM 202-November 2011 (Verified)
DIME Test ID: 2020-10-28-13-3 AASHTO T104-99r16 (Verified)
DIME Test ID: 2020-10-28-13-4 CTM 214-August 2010 (Verified)
DIME Test ID: 2020-10-28-13-5 AASHTO T104-99r16 (Verified)