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Mitchell Sand and Gravel <br />RECEIVED <br />48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 FEB 7 4 20 14 <br />303 - 644 -4102 303 - 870 -4260 cell <br />Division oi�`�i�s��+3fif, <br />Authorization Form for Disposal of Water Based Bentonitic Drilling Flu'n i U44Y <br />From Water Well Drilling Only <br />As required by the Colorado Division of Reclamation Mining and Safety <br />Date:Q <br />Name of Drilling Company, rty, State, Zip (please print) <br />Well Location/Job Site of Drilling Fluid (please print) <br />PY% ct %/a9'.!' <br />� Id 6n,-st ll/4 tr 1e//-o �rOe ,2�o' <br />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 Regulations <br />and State of Colorado Regulations. <br />i/ 19P f7 Yh <br />Authorized'Drilling Company Representative (please print) <br />/��_ Date: <br />Authorized Dri mg Company Representative signature <br />Name of Transport Company disposing of above material (please print) <br />Transport Company Representative (please print) <br />Transport Company Representative signature <br />Date: <br />Drilling Fluid Disposal/Destin tion: Mitchell Sand and Gravel Pits Benne CO 80102 <br />Rick Mitchell, Owner <br />