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Chain of Custody & Analytical Request Record <br /> Lust out ho*.Trust Our 40 www.ener lab.com Page of <br /> Account Information ewnginrorrnallon) Re ort Informati n (If different than Accountinforrnation) Comments <br /> Company/Name Company/Name. CMA <br /> conra�e Contaa ; k.•e.�ry jai:na.i �r►,r <br /> Phone r Phone <br /> MaWing Address q Mailing Address f! <br /> City,State.Zip City,State,Zip !�7 (' <br /> Email Email <br /> ive Invoice t3Hard Copy DE41F Receive Report'❑Hard C-py::❑El Receive Report %4,d Copy SCM.0 <br /> PUrchaYe Order 4110te BbtMe Order Special Report/Fomtats. <br /> ❑LEVEL IV ❑NELAC, 13 EDD/EDT(contact iaboratay) ❑Other <br /> Project Information Matrix Codes Analysis Re nested <br /> A- AirAll turnaround Was are <br /> Project Name,PWSID,Pena,etc. Y W- Water standard unless marked as <br /> Soils/ RUSH. <br /> Sampler Name Sampler Phone(y3s1`7 _ s Soli <br /> v. vegwaa, Energy Laboratories <br /> Sample Origin State EPA/State Compliance ❑Yes O No B- Bloassay, A MUST be contacted prior to <br /> MINING CLIENTS, ase Indicate sample m RUSH sample submittal for <br /> pb type. o DMki,g u charges and scheduling— <br /> •Itore has been processed or refined,call before sending. OW-wow � See Instructions page <br /> ❑Byproduct 11(e)2 rtyeterial ❑Unprocessed ore(NOT ground or refined)' Q <br /> Sample Identification Collection ",,,,,�,d Matrix <br /> Name,Location,r containers <br /> f nterval,�cJ Date Time �Sncw. TAT v4ie t <br /> ' 7- 6ill' <br /> 2 7 ttwo ff <br /> a � � !C t-1 <br /> 4 —7-1 `;t> <br /> —Aw oh <br /> g K <br /> 5 <br /> 7 <br /> 3 <br /> t r; <br /> 0 <br /> Custody by( ) Dater Signal Rer by(pool) Datsirime S gnawre <br /> *cord MUST O <br /> be sigMd Rel nqulshgd by(print) Date/Ttrne Signature R N by LaboratarY t) 5 signature <br /> Shipped By Cooler ID(s) J Custody kals t Receipt Temp Te Blank On I Payment Type Amount Receipt Number(caWmeck o*) <br /> N t3N 1�• 13,Z� �l N (� CC Cash Check_ a <br /> In certain circumstances,samples submitted to Energy LaboraIt Inc.ries, may svubcpnG a to <br /> other eftl d laboratories in order to complete the analysis requested. <br /> This serves as notice of this possibility.Ail subeontractaq data will be clearly notated on your analvtiral ro-4 <br />