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Pr' 4. <br />Mitchell Sand and Gavel <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: 011 1 t' 12-0 1 o <br />L_ A "NI Y C-, S l sQ Cc <br />Name of Drilling Company, City, State, Zip (please print) <br />C 4rYr_,eyA)Ag , wY©"*'ti& <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 and <br />non - harmful to soil and /or crops, etc., in accordance with all applicable Federal Regulations <br />and State of Colorado Regulations. <br />Authorized Drilling Company Representative (please print) <br />(2i �� ' <br />Date: <br />Authorized Drilling Company Representative signature <br />L I-:� �j " - kiz STcv,_�Sn\) c <br />Name of Transport Company disposing of above material (please print) <br />, 1 1 I A, <br />y Representative (please print) <br />Date: <br />Company Representative signature <br />Drilling Fluid Disposal/D stmation: Mitchell Sand and Gravel Pits, Bennett CO 80102 <br />166VI <br />Rick Mitchell, Owner <br />