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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 />as required by the Colorado Division of Reclamation Mining and Safety <br />Date: (i1 l 12.C)i <br />‘D -CANER. I ail nis1T 1R2?n/EQS <br />Name of Drilling Company, City, State, Zip (please print) <br />(ecdeaAl (o€?4-a Aye. ,AllteQ) C) - Well Location/Job Site of Drilling Fluid (please print) <br />CTu 12.E D 6-i2ouWA-reg. <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 />Com mission. <br />YA_ 4-che t{ <br />Authorized Drilling Company Representative (please print) <br />Date: (' 1 l CViDt <br />�j <br />Authorized Drilling Company Representative signature t <br />Li rr2 Scavicel L- , <br />Name of Transport Company disposing of above material (please print) <br />Transport Com .any Re.resentative (please print) <br />Trans .'rt Company Repre entative signature <br />Date: 1 ti t f 2015 <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett. CO 80102 <br />Rick Mitchell, Owner <br />