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RECEIVED <br />Mitchell Sand and Gravel FEB 14 2014 <br />48580 14tivy 36 - Y.O. Box 10, Bennett, CO 80102 Division of Reclamation, <br />303 -644 -4102 303- 870 -4260 cell Mining & Safety <br />Authorization Form for Disposal of Water Based Bentonitic Drilling Fluids <br />as required by the Colorado Division of Reclamation Mining and Safety <br />Date : <br />Name of Drilling Company, City, . tate, Zip (please print) <br />Well Locatio Jah 'Site Drilling Fluid (please print) <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 />J'- <br />�� LIre _ <br />Authorized Drilling Company Representative (pleas- <br />please print) <br />zT Date: <br />rized Drilling ompany Representative signature <br />Name of Transport Company disposing of above material (please print) <br />Transport Company R presentative (please print) <br />Date: <br />Transport Company Representative signature <br />Drilling Flu' ' <br />