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Mitchell Sand and Gravel RECEIVED <br />48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 <br />303 - 644 -4102 303 - 870 -4260 cell FEB 14 2014 <br />Authorization Form for Disposal of Water Based Bentonitic Drilling ftf Reclamation, <br />as required by the Colorado Division of Reclamation Mining and Safety <br />�ng $Safety <br />Date: ) 3 <br />G RsS5 kl�C404_11,;(. <br />Co. c:5?/ 6 <br />Name of Drilling Company, City, State, Zip (please print) <br />C4c-_ CJZ�Q A04V - 5c_ ap i ymo—, - �& So <br />Well Location/Job Site of Drilling Fluid (please print) <br />D VAC Aq 1L1.1'1j& IeL l u_v <br />Name /type of Material /Fluid (please print) <br />Drilling Company guarantees that all material to be disposed of, is both non - hazardous 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 />Authoriz Drilling Company Representative (please print) <br />Date: <br />Au orized Drilling Company Representative signature <br />Name of Transport Company disposing of above material (please print) <br />Transport Company Representative (please print) <br />Tratsport Company Representative signature <br />Drilling Flu <br />Date: <br />Rick Mitchell, Owner <br />