Sample Taken Date	03/22/2023	Sample Unique Key	10
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	03/22/2023
Sample type	Acceptance	A brief description of the sample	1x4 concrete aggregates
The quantity of what the sample constitutes	18 CY	From where was the sample collected	Supplier
First name of sampler or witnessed by	Doug	Last name of sampler or witnessed by	Ruff
Title of sampler	Consultant Tester	Telephone number of sampler	5594670032
Laboratory sample identification		Linked DIME Sample ID
The fabricator/manufacturer/facility name	CalPort Hanford Plant	Transportation Laboratory (TL) Number
Inspector Lot Number from the Transportation Laboratory (TL) Form		Structure unique identifier
Structure name	Tul 99 , Ave 264 Abutment 5

Material Type	Aggregate	Source Identification (SMARA, name of Pit or Job Site)	SMARA 91-54-0038
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	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	176H57	Lot number
Sublot number		Aggregate Mix Number	176H57

DIME Test ID: 2023-03-22-10-1 CTM 202-November 2011 (Verified)
DIME Test ID: 2023-03-22-10-2 CTM 202-November 2011 (Verified)
DIME Test ID: 2023-03-22-10-3 CTM 217-June 2011 (Verified)
DIME Test ID: 2023-03-22-10-4 CTM 227-December 2014 (Verified)