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RECEIVED <br />Mitchell Sand and Gravel FEB 14 1201 <br />48580 Hivy 36- P.O. Box 10, Bennett CO X30102 l <br />Division of <br />303 -644 -4102 303 - 870.4260 cell Mirti,,; <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 />�Gw� 1 �iieyt�u�c C�. t;ti�r'ie1n, (0 F(Ut 2 g <br />Name of Drilling Company, City, State, 'Lip (please print) <br />t--70 I Pe e. s � +, <br />Well Location /Job Site of Drilling Fluid (please print) <br />W4 <br />Nanie /type of Material/Fluid (please print) <br />Drilling Company guarantees that all ntaterial to be disposed of, is both non - hazardous and <br />non•har,nful to soil and/or crops, etc., in accordance with ill 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: <br />Authorized Drilling Company Representative signature <br />Name of Transport Company disposing of above material (please print) <br />�ylin 111,�:Ke: <br />Transport Company Representative (please print) <br />.5-;, /Is//3 <br />- - -_ �� — Date: <br />Tran rt Company Repr sentativc signature <br />Drilling Fluid Disposal/Destii $ n: Mitchell Sand and ravel Pits. Ben�zett, CO 80102 <br />i <br />-- nick Mitchell, Owner <br />