N E T T & C P: Orth Ast Ransportation Raining Ertification Rogram

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NorthEast Transportation Training & Certification Program

Random Sampling Test Report ( D3665 ) Date/Time: Weather: Project: Contract #: Contractor: Pay Item #: Source: Plant Type: Lab/Location: Date Rec'd #: Lab Login #: Material ID: Material #: Sample #: Sample Type: QC A-V IA DR Other Sampled By/Cert. #: Random Sample: Yes Lot #: Sublot #: Sample Location: Station: Offset: No

Rev. 10/22/09

CT MA ME NH NY RI VT

D3665

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