Laserfiche WebLink
ADZ Laboratories, Inc.I <br />• <br />t5-,) <br />2773 Downhill Drive Steamboat Springs, CO 80487 (800) 334-5493 <br />Name: John E Trujillo Address: 1900 Main St. <br />Company: Fortune Revenue Silver Mines, Inc. <br />P.O. Box 564 <br />E-mail: jtrujillo@fortuneminerals.com <br />Tele hone: 970-325-7241 Ext 202 <br />Copy Report to: <br />of <br />Name Dianna Stoopnikoff I I E-mail: S opnikoff@fortuneminerals.com <br />com any Fortune Minerals` I Tete hon 250-320-2919 <br />Invoice to: <br />Name Shawna Clubb Address: 1900 Main St. <br />company Fortune Revenue Silver Mines, Inc. P.O. 13 jx 564 <br />E-mail sclubb@fortuneminerals.com Telephone; 970-325-9830 <br />If sample(s) received past holding time (HT), or if insufficient HTremains to cora plate <br />YES <br />Q <br />analysis before expiration, shall ACZ proceed with requested short HT analyse 7 <br />NO <br />f <br />II'HD" Men AOZ MM conle<I clkM for lurcher Inalructbn. I/ rnl[her "YES",nor "NO" Is IrdicsMd, ACZ ivil proceed wNh IM requested wslraef, even If HT is eaplrsd, sW as,s <br />wdl a gwllMd <br />Are samples for SDWA Compliance Monitoring? I II Yes <br />No <br />If yes, please include state forms. Results will be reported to PQI. for Colorado. <br />Sampler's Name: A. Ramsey Sampler's;Site Information I) State CO <br />Zip code 81427 <br />Time Zone Mtn. <br />•I attest tome u,MMic1,r aid wllditr ol,h— sempk. <br />'Samplers Signature: amp ;newnhMampleI.-n eY.laco )dwedfr.,I1 <br />i <br />I under„nd,hM IntenllwWlr -nIII eun the time/dale/Iwuan w <br />MhaWeblStatelaw <br />PROJECT•- • <br />Quote #: BO# B033324 I II En o <br />d <br />po#: Open I I <br />Reporting state for compliance testing: Colorado I 0 <br />Check box if samples include NRC licensed material? © w o <br />�3 <br />2A 5/1/2015 /0 II 8 <br />® <br />© <br />❑ <br />❑ <br />El <br />El <br />El <br />7Well <br />Well 2B 5/1/2015 p I II 8 <br />Q <br />r❑El <br />0 <br />11 <br />III <br />0I <br />© <br />D <br />D <br />❑ <br />o <br />Ill <br />© <br />® <br />�_ <br />a <br />❑ <br />❑ <br />a <br />a <br />II <br />© <br />© <br />o <br />© <br />o <br />❑ <br />❑ <br />o <br />Matra SW (Surface Water) - GW (Ground Water) -1 WW (Waste Waler)I- DW (DrinWng Water) <br />SL (Sludge) SO (Sotl) OL (Oil) Other (Specify) <br />REMARKS <br />See bottles for specific sample times. Please) send copy of results to Nicole Neals at GUA <br />I II I <br />Please refer to ACTS terms 8 cotxlatlons located on the rI everse side of this COC. <br />RELINQUISHED BY: DATE;TIME RECEIVED BY: <br />DATE:TIME <br />I II I. <br />�I <br />FRMAD050 06.14.14 <br />L24101-1505141447 <br />White - Return with sample. <br />Yellow - Retain for y' ur records. <br />Page 29 of 29 <br />