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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: r- y <br />Name of Drilling Company, City, State, Zip (please print) <br />VAT -�o u sd (OC&d -&o ..rs <br />Well Location/Job Site of Drilling Fluid (please print) <br />l-1y12Ro U'AC 5-LuRAY uU47A <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 />Authorized !Drilling Company Repre ntative (please print) <br />Date: /- /- r <br />Authorized Drilling Company Representative signature <br />10Y <br />Name of Transport Company disposing of above material (please print) <br />• /��- �dsMa�n � � Srru�e� <br />Transport Company Repres tive (please print) <br />Date: <br />Tm4sport Company Representative signature <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett. CO 80102 <br />Rick Mitchell, Owner <br />WA <br />