Sample Taken Date	10/20/2023	Sample Unique Key	21
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	10/20/2023
Sample type	Quality Control	A brief description of the sample	aggregate
The quantity of what the sample constitutes	27 CY	From where was the sample collected	Supplier
First name of sampler or witnessed by	Julio	Last name of sampler or witnessed by	Magana
Title of sampler	lab Technician	Telephone number of sampler
Laboratory sample identification	L233069	Linked DIME Sample ID
The fabricator/manufacturer/facility name	Shamrock Materials Petaluma	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)	91-33-0042
The fabricator's/manufacturer's product name for the sample	SL4201CG	The fabricator/manufacturer designation for the sample	SL4201CG
The plant number		A detailed description of where the material sample was collected	Supplier
Where the material sample would have been placed if not sampled	concrete	Primary Aggregate Nominal Size	1 inch
The concrete mix design number	SL4201CG	Lot number
Sublot number		Aggregate Mix Number

DIME Test ID: 2023-10-20-21-1 CTM 202-November 2011 (Verified)
DIME Test ID: 2023-10-20-21-2 CTM 202-November 2011 (Verified)
DIME Test ID: 2023-10-20-21-3 CTM 217-June 2011 (Verified)
DIME Test ID: 2023-10-20-21-4 CTM 227-December 2014 (Verified)