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Mitchell Sand and Gravel <br />48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 <br />303 - 6444102 303 - 870 -4260 cell <br />Authorization Form for Disposal of Water Based Bentonitic Drilling Fluids <br />as required by the Colorado Division of Reclamation Mining and Safety <br />Date: Q,- S ^1 L( <br />9)0 - .3,;;c - /yctif ap?oiC-r- <br />rL &r WZyV S l_xi fi t_7v & 0 p 1 AW0 �. C (? <br />Name of Drilling Company, City, State, Zip (please print) 'qvc 3 / <br />7G <br />Well Location/J <br />rte, <br />of Drilling Fluid (please print) <br />14 -f ak 0 VWVAC ,SLo2 <br />Name /type of Material/Fluid (please <br />Drilling Company guarantees that all material to be disposed of is both non - hazardous <br />and non - harmful to soil and /or crops, etc. pursuant to all applicable Federal and State <br />of Colorado Regulations, including Rule 907 of the Colorado Oil and Gas Conservation <br />Commission. <br />©A?,Y ^'/ _ 7 -,ftI <br />// .0.w v �o <br />Authorized Drilling Company Representative (please print) <br />K_ — Date: <br />Authorized Drilling Company Representative signature <br />FLO-?- 'r ?0'u ocz �.zLwr' �- <br />Name of Transport Company disposing of above material (please print) <br />A- <br />Y S —) <br />P DPgM / 7 C /"I LQ c_L/ AV <br />Transport Company Representative (please print) <br />(L Date: <br />Transport Company Representative signature <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br />Rick Mitchell, Owner <br />