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Labora#ories, Inc.�,3G 2 ;CHAIN <br />of <br />CUSTODY <br />2773 DownhAY arfve STeam6oat Spdirpa. CO 90487 (800) 334493 <br />Report to: <br />Name: Greg McDougall Address, P.O. Box 3388 <br />Com fry. Mid Continent Testing. Inc Rapid City, SD 57709 <br />E -mi: greg@thechemistrylab_com Fele e; 605-348-0111 <br />Copy of Report <br />Name: Same E -=B- same <br />Corn Tele <br />Name. Same Address. <br />Cam ny: <br />E -teal: Telephone <br />n sample(s) received past holding lima (HT}, or H Insuffldent FET rernalne to complete <br />YES <br />analysis before Wirallon, shall AM proceed with requested short HT analyses? <br />NO <br />^wo•w�acer���r+.ww.e.w.rrr.�r■. r��ar�..�wr�.+.S�.ave....+.waw.��.rr.+r..�...,rrrr�w.�.wrr.ra.rww�w <br />Ate samples for SOMA Compllance Monitoring? Yes No <br />tf yes, Please Include stats tomo. Result Will be repotted to PdL for Cobredo. <br />Sampler's Name: Samplers Sib Information stab ap cods <br />Time Zone <br />ti Mr,r*M..eh..��Iw•/a.r.r�w.rk I w1��.nilMlfiYYwwMf.YirIrIAM.ww� <br />Samplers Signature: <br />f <br />PROJECT• <br />Quota #• <br />Reporting stets for cotnpliance lea <br />V <br />Check two it samples include NRC licensed material? © � <br />#1 11/14/2016 1 © Q 10 10 <br />131 <br />Q <br />❑ <br />❑ <br />#2 11/14/2016 <br />1 <br />❑x ©Q <br />0 <br />❑ <br />© <br />® <br />13#3 <br />11/14/2016 <br />1 <br />© � <br />❑ <br />0 <br />E3 <br />1 Q <br />13 <br />#4 11116/2016 <br />1 <br />®®© <br />0 <br />0 <br />0 <br />0 <br />0 <br />#5 11/16/2016 <br />1 <br />© ® <br />❑ <br />Q <br />Q <br />© <br />Q <br />❑ <br />#6 11/16/2016 <br />1 <br />© x <br />❑ <br />❑ <br />© <br />I ❑ <br />❑ <br />Q <br />© 0 <br />Q <br />Q <br />01 <br />© <br />© <br />0 <br />❑ ® <br />© <br />® <br />❑ <br />❑ <br />❑ <br />13 <br />❑ I © <br />© <br />E31 <br />❑ <br />❑ <br />131 0 <br />© <br />® <br />® <br />1 jC1 <br />❑ <br />0 <br />Mwe Isw (&.%. Warr) • GW (G --rd Warr) • WW IW -W Warr) • CW Io tft veer.►) • es. Iswyy • so tom) ol. (CM • oeer (Sp*) <br />Please refer to ACTe terms A conditions boded on the reverse side of this COC. <br />RELINQUISHED s• D BY. <br />.• <br />/aB�L <br />six <br />4 <br />FRMAD050.06.14.14 While - Mum with sample. Yelow - Retain for your records. <br />1.34283-1612131713 Page 15 of 15 <br />