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Local Assistance Procedures Manual EXHIBIT 16-G <br />Corroboration Report (Form MR-0104) <br />State of California - Department of Transportation <br />CORROBORATION REPORT <br />Form MR-0104 (Rev.6/94) <br />File: Materials Category 100 <br />Instructions: Use this form to compare Split -Sample Test results (Acceptance Tester's test results of the <br />Independent Assurance Sample and Tester) <br />NAME (Acceptance Tester) <br />Valid MR-0111 <br />[ ] YES [ ] NO <br />DATE (When the split sample was <br />presented to the Acceptance Tester) <br />DATE(when the Acceptance Tester's <br />results were received by the IAST) <br />DATE (When the Independent Assurance <br />Sampler's & Tester's results were completed. <br />CORROBORATION OF TEST RESULTS <br />ACCEPTANCE TESTER <br />(AT) <br />INDEPENDENTASSURANCE <br />SAMPLER & TESTER <br />(AST) <br />CORROBORATION <br />BETWEEN THE AT <br />AND THE AST <br />TEST PROCEDURE <br />OR <br />CALIFORNIA <br />TEST NUMBER <br />TEST <br />RESULTS <br />SAMPLE <br />ID NUMBER <br />TEST <br />RESULTS <br />SAMPLE <br />ID NUMBER <br />GOOD <br />FAIR <br />POOR <br />(1) SUBSEQUENT ACTION TAKEN FOR POOR CORROBORATION (List all actions taken and follow-up tests performed. <br />Attach copy of each test report. If no action was taken, document reason(s) for no action taken). <br />LAST NAME (Please print) <br />DISTRICT <br />SIGNATURE (Last) <br />AST CERTIFIED? <br />I ]YES I ] NO <br />IF YES, AST CERTIFICATE NUMBER <br />REPORT DATE <br />FM93 1901 M <br />NOTE: ATTACH ALL TEST DATA (Form MR-0107) <br />APPENDIX C <br />Page 16-61 <br />February 1, 1998 <br />