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-ii <br />c <br />vi <br />;3 <br />.Q <br />:C <br />-- IG <br />=cam <br />tl � <br />. / 3 <br />ADZ Laboratories, Inc. <br />• <br />2773 Downhill Drive Steamboat Springs, CO 80487 (800) 334 -5493 <br />Name: John E. Trujillo <br />Address: 1900 Main St. P.O. Box 564 <br />Company: Fortune Revenue Silver Mines, Inc. <br />Ouray, CO 81427 <br />E -mail: jrujillo@fortuneminerals.com <br />Copy Report to: <br />Telephone: 970 -325 -7241 Ext. 202 <br />of <br />Name: Greg Lewicki <br />I <br />I <br />IE-mail: greg @lewicki.biz <br />Company: Lewicki and Associates <br />iTelephone: 303 - 346 -5196 <br />Name: Sherry Tunks <br />Address. 1900 Main St. P.O. Box 564 <br />Company: Fortune Revenue Silver Mines, Inc. <br />Ouray, CO 81427 <br />E -mail: accountspayable @fortuneminerals.com <br />Telephone: 970- 325 -9830 <br />If sample(s) received past holding time (HT), or if insufficient HT remains to complete <br />YES <br />analysis before expiration, shall ACZ proceed with requested short <br />HT analyses? <br />NO <br />rM <br />I-W thm ACZ wld a tact curd la IuNNr InsUmUon. It mldwe "YES" nor ^NO- k indlcaNd. ACZ Wit proand Mth tha ragimstsd aruWy . wan II Mb axplrsd, and data <br />MII ba opoltlad <br />Are samples for SDWA Compliance Monitoring? <br />Yes No <br />It yes, please Include state towns. Results will be reported to PQL for Colorado. <br />Sampler's Name: John Trujillo Sampler's Site Information <br />State CO Zip code 81427 <br />nme zone MT <br />� atWt N Ur adMnUcw and vaidity M tlds wnpla. I undaratral Nat mbiatudbq Na tlemOd <br />'Sampler's Signature: wxh Un aaaipla in rrywy, is — ulds,ad &&W mul punlahacla by State Law. <br />lloetllM <br />or lamprino <br />PROJECT •- • <br />Quote #: Open PO (Surface Water) Revenue Mine <br />m <br />w c <br />w <br />o <br />9 <br />� <br />m <br />50 <br />N <br />Zg <br />to <br />PO#: <br />Reporting state for compliance testing: Colorado <br />Check box if samples include NRC licensed material? <br />SAMPLE IDENTIFICATION <br />DATE-TIME <br />Matri <br />5 <br />Mine Discharge + Creek <br />On Bottles <br />Mine Discharge 2,nly <br />On Bottles <br />2 <br />e Ik <br />c. - <br />0 <br />1 ® <br />0 <br />E31 <br />E31 <br />® <br />1 E <br />E31 <br />E31 <br />0 <br />E31131 <br />El <br />[Efl <br />E31 <br />010 <br />01 <br />a <br />D <br />01 <br />© <br />1 M <br />0113 <br />® <br />1 ® <br />1 <br />Q <br />1 <br />113 <br />Ell <br />0101 <br />011-1 <br />El <br />11 <br />Matrix sw (Surface Water)-,. GW (Ground Water) " WW (Waste Water) " OW (Drinking Water) " SL (Sludge) " SO (Soil) " OL (011) " Other (Specify) <br />REMARKS <br />Please sen y of rep o. na toopnikoff, Fortune Minerals Inc. dstoopnikoff@fortunemineral <br />Please refer to ACZ's terms & conditions located on the reverse side of this COC. <br />RELINQUISHED BY: DATE:TIME <br />RECEIVED BY: <br />DATE:TIME <br />)0 VA i1'V\ <br />0 <br />FRMAD050.03.14.13 White - Retum with sample. Yellow - Retain for your records. <br />0 <br />L21373- 1411211444 Page 33 of 33 <br />