2015-02-09_REPORT - M1990131

• Permit No: M1990131
• IBM Index Class Name: Report
• Doc Date: 2/9/2015
• Doc Name: Annual Fee Report and Map
• From: Mitchell Pit #2
• To: DRMS
• Email Name: TOD
• Media Type: D
• Archive: No

Mitchell Sand and Gravel
48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102
303 - 644 -4102 303 - 870 -4260 cell
A disabled American veteran owned company
Authorization Form for Disposal of Water Based Bentonitic Drilling Fluids
From Water Well Drilling Only
As req 'red by the Colorado Division of Reclamation Mining and Safety
Date: to
Name of Drilling Company, City, StAte, Zip (please print)
Yro 3135 - JjeAs 31350
Well Locatio-n/Joi Site of Drilling Fluid (please print)
Name /type of Material /Fluid (please print)
Drilling Company guarantees that all material to be disposed of, is both non - hazardous and
non - harmful to soil and /or crops, etc., in accordance with all applicable Federal Regulations
and State ,of Colorado Regulations.
Authorizegprilpg Company Representative (please print)
Date: l 0 14
ling Company Representative signature
Company disposing of above material (please print)
Representative (please print)
Company Representative signature
Date: 10 9 A
Drilling Fluid Disposal /Destin n: Mitchell Sand and Gravel Pits, Bennett, CO 80102
R �
Rick Mitchell, Owner