Sample Taken Date	10/27/2023	Sample Unique Key	110
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	10/27/2023
Sample type	Quality Assurance	A brief description of the sample	Paving Concrete (JPCP)
The quantity of what the sample constitutes	4 samples	From where was the sample collected	Job Site
First name of sampler or witnessed by	Josh James	Last name of sampler or witnessed by	Grance
Title of sampler		Telephone number of sampler
Laboratory sample identification		Linked DIME Sample ID
The fabricator/manufacturer/facility name	Coffman Specialties, Inc	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	2201-2
The truck number from where the sample was collected		The batch plant ticket number from where the sample was collected	NA
Concrete batch plant		The fabricator/manufacturer designation for the sample
A detailed description of where the material sample was collected	On site batch plant	Where the material sample would have been placed if not sampled
From Lot No.		Bag Lot No.

DIME Test ID: 2023-10-27-110-1 AASHTO T336-15 (Verified)
DIME Test ID: 2023-10-27-110-2 AASHTO T336-15 (Verified)
DIME Test ID: 2023-10-27-110-3 AASHTO T336-15 (Verified)
DIME Test ID: 2023-10-27-110-4 AASHTO T336-15 (Verified)