Sample Taken Date	10/26/2023	Sample Unique Key	113
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	10/30/2023
Sample type	Department Acceptance	A brief description of the sample	Washed Concrete Sand
The quantity of what the sample constitutes	800 CY	From where was the sample collected	Fabricator
First name of sampler or witnessed by	GERRY	Last name of sampler or witnessed by	ZUBIETA
Title of sampler		Telephone number of sampler
Laboratory sample identification		Linked DIME Sample ID
The fabricator/manufacturer/facility name	Atkinsons Batch Plant Lancaster	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)	91-19-0026::LITTLE ROCK QUARRY
The fabricator's/manufacturer's product name for the sample	JPCP Pavement	The fabricator/manufacturer designation for the sample
The plant number		A detailed description of where the material sample was collected	Conveyor Belt at Plant
Where the material sample would have been placed if not sampled	PCC SLAB	Primary Aggregate Nominal Size	fine
The concrete mix design number	SC1-12622-1	Lot number
Sublot number		Aggregate Mix Number

DIME Test ID: 2023-10-26-113-1 CTM 217-June 2011 (Verified)
DIME Test ID: 2023-10-26-113-2 CTM 202-November 2011 (Verified)
DIME Test ID: 2023-10-26-113-3 CTM 202-November 2011 (Verified)
DIME Test ID: 2023-10-26-113-4 CTM 227-December 2014 (Verified)