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company Name: <br />Energy Fuels Resources <br />Report Mail Address: <br />44 Union Blvd, Suite 600 <br />Lakewood, CO 80228 <br />Invoice Address: <br />Same <br />I IM1l I¦N 111111 <br />Chain of Custody and Analytical Request Record <br />PLEASE PRINT- Provide as much information as possible. <br />Project Name, PWS, Permit, Etc. Sample Origin <br />Whirlwind Mine <br />State: CO <br />Contact Name: Phone/Fax: Email: <br />Zach Rogers 303-974-2151 zrogers@energyfuels <br />.com <br />Invoice Contact & Phone: Purchase Order: <br />Same <br />Special Report/Formats - ELI must be notified <br />prior to sample submittal for the following: o <br />Lm (0) w <br />>:°-OI <br />c? ; D <br />?DvV <br />El A2LA QO <br />ca <br />21- <br />2 <br />-0 <br />i ( <br />i N <br />N <br />El GSA r_1 EDD/EDT(Electronic l <br />6 <br />i <br />_ <br />M <br />1 E <br />F1 POT V/ WTP Data) =c <br />? State: Format• <br /> <br />. a.` C <br />Z EE<Ic <br />? Other: ? LEVEL <br />IV v, >I N <br />? NELAC <br />04 <br />E <br /> E .2 <br />SAMPLE IDENTIFICATION <br /> <br />d ame, Location, Intea Collection <br /> <br />Date ?Col?e?I on <br /> <br />m <br /> <br />MATRIX :5 <br />2' (D <br />U) <br />1 WW Decline <br />2 <br />3 <br />4 <br />5 <br />6 <br />7 <br />6 <br />9 <br />10 <br />Custody Relinquished by (print): <br />Jess Fulbri ht <br />Record Relinquished by (pnn <br />MUST be <br />Signed <br />4121/2010 1340 MST W X X <br />Daterrime: <br />4/22/10 Ca. 1100 MST <br />ICI ? ?? <br />Page 1 of 1 <br />EPA/State Compliance: <br />Yes ? No <br />Sampler: (Please Print) <br />Jess Fulbright <br />Quote/Bottle Order: <br />QMdVI(N,`? <br />R Contact ELI prior to <br />RUSH sample submittal <br />for charges and <br /> C Q scheduling - See <br /> W !? u Instruction Page <br /> 'p <br /> Q 0 <br />0 <br />Comments: <br /> E S <br /> Q <br /> W E <br /> cn 0 <br />X <br />by <br />Sam le Disposal: Return to Client: Lab Disposal: I It \„ -111 -?t7 q ac) - <br />In certain circumstances, samples submitted to Energy Laboratories, Inc. may be subcontracted to other certified laboratories in order to complete the <br />This serves as notice of this possibility. All sub-contract data will be clearly notated on your analytical report. <br />Visit our web site at www.enerqvlab.com for additional information, downloadable fee schedule, forms, and links. <br />-1 Oc <br />On Ice: <br />No <br />Custody Seal ' N <br />Intact N <br />Signature N <br />Match ' <br />requested.