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Mail to: B-SB Residential Metals Program 25 W. Front St. Butte, MT 59701 Fax to: (406) 723-7245 EXHIBIT 3 TO RESIDENTIAL ACCESS AGREEMENT SAMPLE REQUEST I, the undersigned, am the owner, his/her legal representative, or otherwise control the Property described herein. I have granted access to BSB and their representatives, to enter the Property and to take samples of environmental media from the Property. I hereby request BSB provide to me a report of the results of that sampling. Signature of person making request (if made on behalf of another person or company, please identify that party also): Signature Print Name: The following is the address at which the requesting party may be contacted and/or the sample portion delivered: - 8 - ---PAGE BREAK---