Sample Taken Date	10/04/2021	Sample Unique Key	33
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	10/05/2021
Sample type	Department Acceptance	A brief description of the sample	3/4" Class II AB
The quantity of what the sample constitutes	2 bags	From where was the sample collected	Manufacturer
First name of sampler or witnessed by	Karl	Last name of sampler or witnessed by	Huntman
Title of sampler	JET	Telephone number of sampler
Laboratory sample identification	D78946	Linked DIME Sample ID
The fabricator/manufacturer/facility name	Mountain Gate Quarry	Transportation Laboratory (TL) Number	853080
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)	91-45-0001
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	Stockpile
Where the material sample would have been placed if not sampled	02 SIS 5	Primary Aggregate Nominal Size	1/2 inch
The concrete mix design number		Lot number	Unknown
Sublot number	Unknown	Aggregate Mix Number	Not set

DIME Test ID: 2021-10-04-33-1 CTM 202-November 2011 (Verified)
DIME Test ID: 2021-10-04-33-2 CTM 217-June 2011 (Verified)
DIME Test ID: 2021-10-04-33-3 CTM 229-June 2011 (Verified)
DIME Test ID: 2021-10-04-33-4 CTM 301-March 2000 (Verified)