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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: I-1_ <br />K <br />Name of Drilling CuuJpany, City, State, Zip (please print) <br />`7v v 6n , S, i - t e n aI - <br />f <br />Well Location/Job Site of Drilling Fluid (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 />(?,04A DPLOCt LL'finL3 <br />0 <br />Authorized Drilling Company Representative (please print) <br />Date: <br />A rite Drilling Company Representative signature <br />Name of Transport Company disposing of above material (please print) <br />Transport Company Representative (please print) <br />Date: <br />Transport Company Representative signature <br />Drilling Fluid Disposal/Desti tion: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br />Rick Mitchell, Owner <br />