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Mitchell Sand and Gravel <br />48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 <br />303 - 6444102 303 - 8704260 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: 2.7 20/ <br />L.A yNE �}� Q: s i rw�5� 4P. A yR_o aA j C D `a 001 j <br />Name of Drilling Company, City, State, Zip (please print) <br />q(„ w -Doa>LAs T3Lvt�, (_,Ati_..s-�v fL ( Co <br />Well Location/Job Site of Drilling Fluid (please print) <br />QATCn <br />Name /type of Material/Fluid (please print) <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 />-7; w. tAkr <br />Authorized Drilling Company Representative (please print) <br />_'00� 2 <br />Date: <br />Authorized Drilling Company Representative signature <br />L A1jNE Cka- 57d-YO sVINJ 4LO <br />Name of Transport Company disposing of above material (please print) <br />Transport Company Representative (please print) <br />Date: <br />ransport Company Representative signature <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett, CO 80102 <br />Rick Mitchell, Owner <br />