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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: 7/3// _ <br />Y z'b40 kFSOgkcE 5' 13027 coow -f' AO ! R- Tew, c©. ke6: <br />Name of Drilling Company, City, State, Zip (please print) <br />3ZR' ,7.4r.Kc,- ,j i ,L- <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 Colorad Re Wa <br />Authori rilling C pany Representative (please print) <br />t_--- _ <br />Date: <br />Auth zed Drilling pany Representative signature <br />__­z <br />&/ /o <br />Name of Transport Company disposing of above material (please print) <br />Transport Company Representative (please print) <br />Date: <br />nsport Company Representative signature <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett CO 80102 <br />Rick Mitchell, Owner <br />".e ".we ;, <br />