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ADZ Laboratories, Inc. �� �' <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. 'Ill P.O. Box 564 <br />E-mail. jtrujillo@fortuneminerals.com Telephone:, 970-325-7241 Ext 202 <br />Copy Report to: <br />• <br />of <br />Name Dianna Stoo nikoff <br />P <br />E-mail: stoopnikoff@fortuneminerals.com <br />fortuneminerals.com <br />Company: Fortune Minerals <br />Tele hone: 250-320-2919 <br />I <br />Invoice to: <br />Name Shawna Clubb Address 1900 Main St. <br />Company Fortune Revenue Silver Mines, Inc. P.O. Box 564 <br />E-mail sclubb@fortuneminerals.com Telephone 1970-325-9830 <br />If samples) received past holding time (HT), or if insufficient HT remains to complete <br />I It <br />analysis before expiration, shall ACZ proceed with requested short HT analyses? <br />1 11 If "NO" than AGI wih contact client enr Ivr lh— Instruction. If neither 'YES" —r 0",. mdicated, ACZ wdi proceed wdh the requested analyses, even if HT Is eap—, and data <br />YES LQ <br />NO <br />will W —lin <br />Are samples for SDWA Compliance Monitoring? I II YesLM No x <br />If yes, please include state forms. Results will be reported to PQL for Colorado. <br />Sampler's Name: A. Ramsey Sampler's Site Information <br />II <br />•t attest to the authentkltY <br />`Samplers Signature: nnw n■ wlib the :a " <br />PROJECT INFORMATION <br />State CO I Zip code 81427 Time Zone Mtn. <br />and validity d Ihis M^�. 1 uaaenta.w tial iMenuoraily miJabeliry the time/date/lasatien ar <br />le in anyway. Is renllrrod haud aM iwa 10,ble by Slate L— <br />Quote #: BO# B033324 <br />o <br />U <br />o <br />u <br />o <br />o <br />3� <br />�a <br />Po#: Open <br />Reporting state for compliance testing: Colorado I <br />Check box if samples include NRC licensed material? I <br />SAMPLE • • •• <br />Well 3A 5/1/2015 I I <br />8 <br />x <br />© <br />0 <br />D <br />D <br />Well 313 5/1/2015& i% I I <br />8 <br />0 <br />0 <br />0 <br />0 <br />i❑ <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />o <br />o <br />©© <br />o <br />D <br />o <br />a <br />c •� �; l <br />i <br />� <br />� <br />D <br />O <br />D <br />D <br />D <br />II <br />© <br />0© <br />I <br />D 1 <br />0© <br />1 o <br />0 <br />DID <br />01 <br />0 <br />1 0o <br />I D <br />o <br />it <br />I <br />11.1 <br />D <br />01 <br />01 <br />D <br />D <br />1 D <br />D <br />Matrix SW (Surface Water) GW (Ground Water) WW (Waste Waler) Il DW (Dnnking Wale, <br />SL (Sludge) I SO (Soil) OL (Oil) Other (Specify) <br />I� <br />See bottles for specific sample times. Please send copy of results to Nicole Neals at GL&A <br />Please refer to ACZ's terms & conditionsItoI ted on the reverse side of this COC. <br />RELINQUISHED • • • : ■ <br />% / /S II <br />I II I <br />FRMAD050.D6.14.14 <br />L24099-1505151407 <br />White - Return with sample <br />Yellow - Retain for your records. <br />i <br />Page 29 of 29 <br />