Sample Taken Date	12/07/2022	Sample Unique Key	37
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	12/16/2022
Sample type	Verification	A brief description of the sample	3/4" HMA-A-SP R12 0.75%LAS
The quantity of what the sample constitutes	1 bag	From where was the sample collected	Manufacturer
First name of sampler or witnessed by	Matich QC	Last name of sampler or witnessed by	Matich QC
Title of sampler		Telephone number of sampler
Laboratory sample identification	0779A-22	Linked DIME Sample ID
The fabricator/manufacturer/facility name	Matich Plant Rialto	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)	91-36-0040
The fabricator's/manufacturer's product name for the sample		The fabricator/manufacturer designation for the sample	Plant
The plant number		A detailed description of where the material sample was collected	Conveyor Belt
Where the material sample would have been placed if not sampled		Primary Aggregate Nominal Size	3/4 inch
The concrete mix design number	LHP-62D	Lot number
Sublot number		Aggregate Mix Number

DIME Test ID: 2022-12-07-37-1 AASHTO T27-14 (Verified)
DIME Test ID: 2022-12-07-37-2 AASHTO T176-08 (Verified)
DIME Test ID: 2022-12-07-37-3 CTM 202-November 2011 (Verified)
DIME Test ID: 2022-12-07-37-4 CTM 202-November 2011 (Verified)