Sample Taken Date	01/07/2022	Sample Unique Key	3
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	01/07/2022
Sample type	Per Request	A brief description of the sample	A set of 6 LCB RS cylinders
The quantity of what the sample constitutes	Trail Batch	From where was the sample collected	Source
First name of sampler or witnessed by	Marcus	Last name of sampler or witnessed by	Molina
Title of sampler	Field Materials Tester	Telephone number of sampler	9095343477
Laboratory sample identification	220026	Linked DIME Sample ID
The fabricator/manufacturer/facility name	Security Paving Burbank Batch Plant	Transportation Laboratory (TL) Number
Inspector Lot Number from the Transportation Laboratory (TL) Form		Structure unique identifier
Structure name	Trial Batch

Material Type	Concrete	The concrete mix design number	G322LRS271
The truck number from where the sample was collected	Load 1	The batch plant ticket number from where the sample was collected	224686
Concrete batch plant	Security Paving Burbank Batch Plant	The fabricator/manufacturer designation for the sample	Trial Batch
A detailed description of where the material sample was collected	Concrete from wheelbarrow	Where the material sample would have been placed if not sampled	Trial slab
From Lot No.		Bag Lot No.

DIME Test ID: 2022-01-07-3-1 ASTM C39-21 (Verified)
DIME Test ID: 2022-01-07-3-2 CTM 521-June 2020 (Verified)
DIME Test ID: 2022-01-07-3-3 CTM 521-June 2020 (Verified)
DIME Test ID: 2022-01-07-3-4 CTM 521-June 2020 (Verified)