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0 <br />w <br />0 <br />11 <br />AUZ Laboratories, Inca <br />2773 Downhill Drive Steamboat Springs, CO 80487 (800) 334, U 3 <br />Name John E Trujillo I, Address:, 1900 Main St. <br />Compan : Fortune Revenue Silver, Mines, Inc. P.O. Box 564 <br />E-mail: trujill0 fortuneminerals.com I Telephone: 970-325-7241 Ext 202 <br />ReportCopy of <br />Name: Dianna Stoopnikoff I E-mail: Sioopnikoff@fortuneminerals.com <br />Com an : Fortune Minerals I I Tele hone: 250-320-2919 <br />Invoice to: <br />Name: Shawna Clubb Address: 11900 Main St. <br />Company: Fortune Revenue Silver Mines, Inc. P.O. Box 564 <br />E-mail: sclubb@fortuneminerals.com Tele none: 970-325-9830 <br />If sample(s) received past holding time (HT), or If Insufficient HT remains to complete <br />YES <br />X <br />analysis before expiration, shall ACZ proceed with requested short HT analyses? <br />NO <br />rM <br />f'NO' •Nn ACS wlp corYsl dNnt b n,luur In.huctlw,_ I/ n.IMM 'YEe' M.'NO' b IMfcnop, ACZI`MII P—i Mlh do nqu..bd .IW y..., — If HT 1...pl—1, am dMft will b. 9"ISW <br />Are samples for SOWA Compliance Monitoring? I Yes No x <br />N <br />If yes, please include state forms. Results will be reported to PCO for Colorado/ <br />Sampler's Name: A. Ramsey Sampler's Site information II State CO! Zip code 81427 <br />Time Zone Mtn. <br />•i MIM 4 n.IW kHv..dr d u•..n^iM. I..d.nl.M eW bl.nd.H.11y •nbl.bin[ d» u,../e.b/I.<Mbw a <br />*Sampler's Signature: /.•..•ti[ .eb. e,.'ompl. M a yw.y, b ro da«w n. w..e punbMbl. by Sb . <br />PROJECT•• • <br />cote #: BO# B033324 <br />m Po*: Open Open ; I II : <br />Reporting state for compliance testing: Colorado I II c <br />0 <br />U <br />Check box if samples include NRC licensed material? EI c <br />m <br />IDENTIFICATIONSAMPLE e• st c3 <br />Well 1A 5/1/2015 •r I II 8 ❑ ❑ ❑ ❑ <br />❑ <br />❑ <br />❑ <br />Well 1 B 5/1/2015 i II 8 <br />Q <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />[] <br />❑ <br />4 I II <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />I <br />❑ <br />❑ <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />�'II <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />El <br />1I <br />❑ <br />❑ <br />❑ <br />01 <br />❑ <br />01 <br />❑ <br />❑ <br />III <br />❑ <br />❑ <br />❑ <br />❑ <br />11 <br />EN <br />❑ <br />11Ii <br />El <br />1:10 <br />1:11 <br />❑ <br />CH <br />❑ <br />❑ <br />II <br />❑ 1 <br />❑ <br />ffl <br />❑ I <br />❑ <br />❑ 1 <br />❑ <br />❑ <br />Matrix sW (surface Water) GW (Ground Water) WW (Waste water), Dw (Drinking Watei) Sl (sludge) SO (Soil) OL (Oil) otter (specity) <br />IIII <br />See bottles for specific sample times. Please send <br />copy oTi results to Nicole Neals at GL&A <br />i <br />I <br />Please refer to ACZ's teams 8 conditions located <br />II <br />on the reverse side of this COC. <br />RELINQUISHED s• <br />Ap.�S <br />II <br />II <br />FRMAD050.08.14.14 <br />L24100-1505151408 <br />White - Retum with sample. <br />Yellow - Retain for your records. <br />I <br />I <br />I <br />I <br />Page 31 of 31 <br />