Sample Taken Date	08/17/2022	Sample Unique Key	84
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	08/25/2022
Sample type	Acceptance	A brief description of the sample	1 x 4 PCC Aggregate and Sand
The quantity of what the sample constitutes	100 cys	From where was the sample collected	Fabricator
First name of sampler or witnessed by	Gerry	Last name of sampler or witnessed by	Zubieta
Title of sampler	TRANSPORTATION ENGINEER CIVIL	Telephone number of sampler
Laboratory sample identification	7576	Linked DIME Sample ID
The fabricator/manufacturer/facility name	Short Load Concrete 60/15 freeway Portable	Transportation Laboratory (TL) Number	C-924247
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)	91-33-0027
The fabricator's/manufacturer's product name for the sample		The fabricator/manufacturer designation for the sample	Portable Plant
The plant number		A detailed description of where the material sample was collected	Conveyor Belt feeding weight hopper at the Plant
Where the material sample would have been placed if not sampled	PCC SLAB	Primary Aggregate Nominal Size	1 inch
The concrete mix design number	G3-19-PCC-172	Lot number
Sublot number		Aggregate Mix Number	Not set

DIME Test ID: 2022-08-17-84-1 CTM 202-November 2011 (Verified)
DIME Test ID: 2022-08-17-84-2 CTM 227-December 2014 (Verified)
DIME Test ID: 2022-08-17-84-3 CTM 217-June 2011 (Verified)
DIME Test ID: 2022-08-17-84-4 CTM 202-November 2011 (Verified)