Sample Taken Date	09/27/2023	Sample Unique Key	85
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	09/29/2023
Sample type	Quality Assurance	A brief description of the sample	6x12 concrete cylinders
The quantity of what the sample constitutes	3	From where was the sample collected	Job Site
First name of sampler or witnessed by	T Tran	Last name of sampler or witnessed by	T Tran
Title of sampler		Telephone number of sampler
Laboratory sample identification	23-0291	Linked DIME Sample ID
The fabricator/manufacturer/facility name	Robertson's - Anaheim	Transportation Laboratory (TL) Number
Inspector Lot Number from the Transportation Laboratory (TL) Form		Structure unique identifier
Structure name

Material Type	Concrete	The concrete mix design number	SC590B38
The truck number from where the sample was collected		The batch plant ticket number from where the sample was collected	1
Concrete batch plant		The fabricator/manufacturer designation for the sample
A detailed description of where the material sample was collected	Concrete from wheelbarrow	Where the material sample would have been placed if not sampled	RTE 91 PM 5 RT CIDH
From Lot No.		Bag Lot No.

DIME Test ID: 2023-09-27-85-1 CTM 521-June 2020 (Verified)
DIME Test ID: 2023-09-27-85-2 CTM 521-June 2020 (Verified)
DIME Test ID: 2023-09-27-85-3 CTM 521-June 2020 (Verified)
DIME Test ID: 2023-09-27-85-4 CTM 521-June 2020 (Verified)