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Mitchell Sand and Gravel <br />RECEIVED <br />48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 FEB 14 2014 <br />303 - 644 -4102 303 - 870 -4260 cell <br />DMsion of Reclamation, <br />Authorization Form for Disposal of Water Based Bentonitic Drilling Flu�idss <br />From Water Well Drilling Only <br />As required by the Colorado Division of Reclamation Mining and Safety <br />Date: l 7-3 Z-n 13 <br />4evo E_ ';�V 4t.)• <br />C <br />Name of Drilling Company, City, State, Zip (please print) <br />L.F. <br />v 25 � I I © L,J tAA <br />Well Location/Job Site of Drilling Fluid (please print), <br />C_u 11 ,jL s AKv7 ---L > ?Z, L L',.jG FL i., r L) <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 Regulations <br />and State of Colorado Regulations. <br />Authorized Drilling Company Representative (please print) <br />Date: -1 �2_3 / 2-o 13 <br />Authorized Drilling Company Representative signature <br />Name of Transport Company disposing of above material (please print) <br />Transport Company Representative (please print) <br />Date: <br />Transport Company Representative signature <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br />Rick Mitchell, Owner <br />