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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 />16,3 <br />*118 1e%liS <br />A disabled American veteran owned company <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: //6// <br />1-7/yDRt) 4,5,91.413C5s /)cV C-/3 f -L..4 ,0 co-- : e)G,7;/ <br />Name of Drilling Company, City, State, Zip (please print) <br />4.;01) LICA WirrIA I2 fi — L/ "+A Ct. Lc? ,,ZUP ‘97,1-1A1/Jack <br />Well Location/Job Site of Drilling Fluid (please print) <br />✓RILL CL i r/NL$ ,' /L f ito <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 Regulations <br />and State of Colorado Regulations. If adverse weather (rain, snow), please contact me <br />first: tracking mud from the pit onto Highway 36 is not permitted by CDOT. <br />�61's <br />e.— <br />Authorized <br />r <br />Authorized Drilling Company Representative (please print) <br />=loriz illing Company Representative signature <br />Date: //7/:-/Y <br />Name of Transport Comp p print) <br />es0v/G r5 �? L 44% - <br />Company disposin of above material (please <br />Transport Company Representative (please print) <br />ansport Company Representative signature <br />Date: /1-7/-2,e <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br />Rick Mitchell, Owner <br />