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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 />A disabled American veteran owned company <br />Authorization Form for Disposal of Water Based Bentonitic Drilling Fluids <br />From Water Well Drilling Only <br />As required by the Colorado Division of Reclamation Mining and Safety <br />Date: 11 17- 1 zg-( <br />L AY^t6 Co, <br />Name of Drilling Company, City, State, Zip (please print) <br />,CC4f. V Co. <br />Well Location/Job Site of Drilling Fluid (please print) <br />fLc'ViNV M( ! <br />Name /type of Material/Fluid <br />(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 />�T� w• l-lALf <br />Authorized Drilling Company Representative (please print) <br />L" _�� Date: I ( zb <br />Authorized Drilling Company Representative signature <br />L,k., f C_kLZ! l a-n)Sb�v Co <br />Name df Transport Company disposing of above material (please print) <br />LA <br />Transpok Company Representative (please print) <br />Date. I 1 <br />i Transport Company Representative signature <br />Drilling Fluid Disposal/Destina 'on: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br />Rick Mitchell, Owner <br />