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Mitchell Sand and Gravel <br />48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 <br />303 - 644 -4102 303 -870 -4260 cell <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: f <br />J <br />Name of Drilling Company, City, State, Zip (please print) <br />Well Location/Job Site of 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 <br />and non - harmful to soil and /or crops, etc. pursuant to all applicable Federal and State <br />of Colorado Regulations, including Rule 907 of the Colorado Oil and Gas Conservation <br />Commission. <br />yy /^1 <br />Authorized Drilling Company Representative (please print) <br />Date: <br />Authorized Drilling Company Representative signature <br />f��D�R�x, �• '7.� 378 - X893 SoS- �d5�- � 99 � <br />Cd%t�ss' a'o, <br />Name of Transport Compan disposing of above material (please print) <br />Transport Company Representative (please print) <br />Date: <br />Transport Company Representative signature <br />'Pe �2 <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett, CO 80102 <br />Rick Mitchell, Owner <br />CL, °mil <br />