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Mitchell Sand and Gravel <br />48580 Hivy 36 - P.O. Box 10, Bennett, CO 80102 FEB 14 2014 <br />303 - 644. 4102 303- 870 -4260 cell Division <br />of k ®claâ–ºnati <br />Authorization Form for Disposal of Water Rased Bentonitic Drilling fNaIN i ri'4n "" on <br />as required by the Colorado Division of Reclamation Mining and Safety <br />Date:' <br />Nance of Drilling Company, City, State, Zip (please print) <br />OR <br />I <br />ob Site of Drilling Fluid (please print) <br />Name /type of Material /Fluid (please priatt) <br />Drilling Company guarantees that all material to be disposed of, is both non- liazardous and <br />non - harmful to soil and/or crops, etc., in accordance with all applicable Federal and State <br />of Colorado Regulations, Including Rule 907 of the Colorado Oil and Gas Conservation <br />Commission. <br />Authorized Drilling Company Representative (please print) <br />Date: J <br />Au orized Drilling Company Representative signature <br />Name of Transport Company disposing <br />above material (please print) <br />- A ) k " tLy," <br />Transport Compan Representative (please print) <br />transport Company Representative signature <br />Drilling Flu <br />Date: <br />