Sample Taken Date	12/14/2023	Sample Unique Key	3
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	12/14/2023
Sample type	Quality Assurance	A brief description of the sample	1 x 4 PCC Aggregate
The quantity of what the sample constitutes	4 CY	From where was the sample collected	Supplier
First name of sampler or witnessed by	mike	Last name of sampler or witnessed by	bennett
Title of sampler		Telephone number of sampler
Laboratory sample identification		Linked DIME Sample ID
The fabricator/manufacturer/facility name	CEMEX Santa Barbara	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)	High Grade - Little Rock
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	1 inch
The concrete mix design number	1614705	Lot number
Sublot number		Aggregate Mix Number

DIME Test ID: 2023-12-14-3-1 CTM 202-November 2011 (Verified)
DIME Test ID: 2023-12-14-3-2 CTM 202-November 2011 (Verified)
DIME Test ID: 2023-12-14-3-3 CTM 217-June 2011 (Verified)
DIME Test ID: 2023-12-14-3-4 CTM 227-December 2014 (Verified)