<p> Jensen Technologies, LLC </p><p>Website: jensentechnologiesllc.com 15985 South Golden Road, Unit H Golden, CO 80401 Cell: 303-478-3929 E-mail: [email protected] SAMPLE SUBMISSION FORM Please include this form with samples (please print)</p><p>Today’s date: Project N0: Purchase order number: Date results are required: Project Name: Price: COMPANY INFORMATION (OR INCLUDE BUSINESS CARD) Company name: Contact for report: Phone number: Fax number: Street address: P.O. box: City: State: ZIP Code: </p><p>DESCRIPTION OF WORK REQUESTED Sample # Matrix Sample/Reference description (used in final report) Analytes</p><p>1 Check the Analyte required See Page 3&4 2</p><p>3</p><p>4</p><p>5</p><p>6</p><p>7</p><p>8</p><p>9</p><p>10</p><p>Number of samples: Date Received: Comments, including special billing, safety precautions, estimated sample value: There will be a sampling and handling fee for outside labs. All outside analysis will be billed directly. The terms are NET 15 days. No rush charges. The minimum is $50.</p><p>REPORTING (STANDARD TURNAROUND FOR RESULTS ARE 5 WORKING DAYS AFTER RECEIPT OF SAMPLE)  No report X Standard turnaround DISPOSITION OF SAMPLES AFTER ANALYSIS </p><p> Discard samples after 3 months X Return samples after analysis Forward samples on to:</p><p>Include Contact: * Extra charge</p><p>1 Authorization Signature: Date: Project Manager </p><p>2 Price List Effective Jan. 1, 2011 Oil & Gas Produced Waters Water-Wastewater-Process Solutions-EMS Feed, Permeate, Concentrate Analyte Symbol Method Price $</p><p>Aluminum Al AA 20</p><p>Ammonia NH3-N Salicylate Colorimetric 20 Antimony Sb AA 20 Arsenic As GA-AA 50 Barium Ba AA 20 Boron B Carmine Photometric 20 Cadmium Cd AA 15 Calcium Ca AA 20</p><p>Carbon Dioxide tCO2 Gas Sensing Electrode 30 = Carbonate CO3 ASTM D513-82F - Bicarbonate HCO3</p><p>Chloride Cl- Mercuric Nitrate Titration 20 Chromium, Hexavalent Cr+6 Diphenylcarbohydrazine 20 Total Chromium tCr AA 20 Cobalt Co AA 15 Conductivity Electrode 15 Copper Cu AA 15 Cyanide, Free fCN- ISE Standard Addition 25 Silver Nitrate Titration Eh (ORP) Eh Pt Electrode 15 Fluoride F- ISE 25 Free Acid as Sulfuric Acid FA pH Titration 35 Hardness, Ca + Mg Hardness AA 30 Iron Fe AA 15 Iron, Ferrous Fe+2 Dichromate Redox Titration 20 Iron, Ferrous Fe+2 1,10 Phenanthroline 255 20 (0.02-3.00 mg/L Iron, Ferric Fe+3 Difference tFe- Fe+2 25 Lead Pb AA 15 Lithium Li AA 15 Magnesium Mg AA 20 Manganese Mn AA 15 Molybdenum Mo AA 20 Molybdenum as Mo+6 Mo+6 Ternary Complex 20</p><p>3 Nickel Ni AA 15</p><p>Nitrate NO3-N Dimethylphenol 20</p><p>Nitrite NO2-N Diazotization 20 pH Electrometric 10 Phosphorous, Ortho . Ascorbic Acid 20</p><p>-3 Phosphorous, Total PO4 -P Digestion-Ascorbic Acid 25 Potassium K AA 15 Selenium Se GA-AAS 50</p><p>Silica SiO2 Silicomolybdate 20 Silicon Si AA 20 Silver Ag AA 15</p><p>4 Sodium Na AA 15 Solids, Total TS Gravimetric 20 Solids, Dissolved TDS Gravimetric 20 Solids, Suspended TSS Gravimetric 20 Specific Gravity S.G. Gravimetric 25 Strontium Sr AA 20</p><p>Sulfate SO4 Turbidimetric 20</p><p>Sulfide, Free S-2 ISE 50 Thallium Tl AA 20 Thiocyanate SCN Photometric 25 Titanium Ti AA 20 Turbidity NTU Nephelometric 15 Vanadium V AA 20 Zinc Zn AA 15 Salinity NaCl Conductivity Meter 25</p><p>Total Metals Digestion HCl-HNO3 25 Total Dissolved Solids TDS Conductivity Meter 15 Guar Guar Phenol-Sulfuric 50 Photometric Temperature º C Thermometer 10 Gold Au AAS-Std Add 50</p><p>Carbon, Total Organic TOC Persulfate Digestion-CO2 50 Detection Oil & Grease O&G EPA Method 1164 63.00** Total Petroleum Hydrocarbons TPH EPA Method 1664 75.00*</p><p>TPH (C6-C32) GRO + DRO GRO- DRO SW-846 8015M 150.00*</p><p>GRO = Gasoline range organics *Wyoming Analytical Labs DRO = Diesel range organics **ACUTEST Mountain States There will be a minimum charge of $50.</p><p>5</p>