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Date: <br />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 />From Water Well Drilling Only <br />As required by the Colorado Division of Reclamation Mining and Safety <br />37/v//6 <br />YdRo 4456(Age_fi$ /9622 ci? l8 /1:7- tep;w Co. <br />Name of Drilling Company, City, State, Zip (please print) <br />PM)f /E I%!nt) WA -TEA - 1424-77<m).5 Cb &t /32 <br />Well Location/Job Site of Drilling Fluid (please print) <br />t.A.)&44— it,k)e,t1 LOcAtex <br />ame/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 />Authorized Drilling Company Representative (please print) <br />Authoriling Company Representative signature <br />Date: <br />Transport Company <br />Na p pa y di sposing of above material (please print) <br />Name o <br />Transport Company Representative (please print) <br />Trar(spj-t Company Representative signature <br />Date: I ' c% I 1 W <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br />Rick Mitchell, Owner <br />6,06.2/ <br />