Sample Taken Date	12/14/2020	Sample Unique Key	15
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	12/15/2020
Sample type	Department Acceptance	A brief description of the sample	3/8" HMA-A-SP R15 0.5% LAS
The quantity of what the sample constitutes	2 Bags Of Coldfeed Agg., 1 Bag Rap	From where was the sample collected	Manufacturer
First name of sampler or witnessed by	California Commercial Asphalt Lake Elsinore	Last name of sampler or witnessed by	QC
Title of sampler		Telephone number of sampler
Laboratory sample identification	0698A-20	Linked DIME Sample ID
The fabricator/manufacturer/facility name	California Commercial Asphalt - Lake Elsinore	Transportation Laboratory (TL) Number
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)	91-33-0098, 91-33-0011
The fabricator's/manufacturer's product name for the sample	3/8 HMA-A-SP R15	The fabricator/manufacturer designation for the sample
The plant number	53891193	A detailed description of where the material sample was collected	Belt Cut at California Commercial Asphalt Lake Elsinore Plant at 116 Tons
Where the material sample would have been placed if not sampled	Asphalt Paving	Primary Aggregate Nominal Size	3/8 inch
The concrete mix design number		Lot number
Sublot number		Aggregate Mix Number	Not set

DIME Test ID: 2020-12-14-15-1 AASHTO T27-14 (Verified)
DIME Test ID: 2020-12-14-15-2 AASHTO T176-08 (Verified)
DIME Test ID: 2020-12-14-15-3 CTM 202-November 2011 (Verified)
DIME Test ID: 2020-12-14-15-4 CTM 202-November 2011 (Verified)