Laserfiche WebLink
Date: <br />Mitchell Sand and Gravel, <br />48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 <br />303 -644 -4102 303 - 8704260 cell <br />A disabled American veteran owned company <br />Authorization Form for Disposal of Water Based Bentonitic Drilling Fluids <br />as required by the Colorado Division of Reclamation Mining and Safety <br />?�;jJC-4-4 D►L, 1(2%-- CCN?AO+ . Lit 615 �5 MAd 5, 9E DO 4 Ca $00{(0 <br />Name of Drilling Company, City, State, Zip (please print) <br />U' li;;,.gAQ '36 S�io+ ; I SS, , h A PAW 61y,ld,00, <br />Well Location/Job Site of Drilling Fluid (please print) <br />A&6W [. AW iy rLU;p - �a turesku To '". PZ V,txtS <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 />ttu <br />Authorized r'Iling mp epresentative (please print) <br />/r <br />Authorized Drilling 6on#Idny Representative signature <br />Date: 1 "11'Y. <br />A-W 01Lo Uj) 5Vers <br />Name of Transport Company disposing of above material (please print) <br />0 7—P <br />Transport Company Representative (please print) <br />/M Date: <br />Transport Company Representative signature <br />Drilling Fluid Disposal /Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br />Rick Mitchell, Owner <br />