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 required by the Colorado Division of Reclamation Mining and Safety
Date: //,q
r
of Drilling Company, City,
Vr) ' Co SO4 P_ I
Zip (please print)
Well Location/Job Site of Drilling Fluid (please print)
M ?A [.tOAy�tr1� (n..C�.�t�
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.
- -�191 &3cu-'e,
Authorized Drilling Company Representative (please print)
W1 1-11, Date: 09/Wl
A ed rilling Company Representative signature
of Transport Company disposing of above material (please print)
Transport Company Representative (please print)
Date:
Transport Company Representative signature
Drilling Fluid Disposal /Destio4ion:
Rick Mitchell, Owner