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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 />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: L2—;- so ! <br />LikytA Ckxwgnjsga <fo /--aaa 6- 22+zAaF AvvpaA Ca 190U1 <br />Name of Drilling Company, City, State, Zip (please print) <br />CDs <br />Well Location/Job� Site of Drilling Fluid (plea a print) <br />Name /type of MateriaVFluid (please print) <br />1"N65 Co q�'M2-1 <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 />N-• PALE <br />Authorized Drilling Company Representative (please print) <br />_X � Date: 2 S IM-1i <br />Authorized Drilling Company Representative signature <br />Name of Transport Company disposing of above material (please print) <br />Transport,Company Rep sentative (please print) <br />Date: 7 2S i <br />Tr sport Company Representative signature <br />Drilling Fluid Disposal/Dyh)ination: Mitchell <br />Rick Mitchell, Owner <br />