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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 />From Water Well Drilling Only <br />As required by the Colorado Division of Reclamation Mining and Safety <br />Date: M// <br />?7141' <br />YDEo &$wcis /Ji 2P CR )8 Fr L' p-mv, Citi X6.71 <br />Name of Drilling Company, City, State, Zip (please print) <br />4P:)P}-{DE CowL 1.4>14 A)4,STF i' h- -R <br />Well Location/Job Site of Drilling Fluid (please print) <br />e -40 &,/ /c �j( /(( l'v�j -/!//U <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 />Authorized Drilling Company Representative (please print) <br />orized iifing Company Representative signature <br />Date: 3" -/d / 6 <br />Name of ransport Company disposing of above material (please print) <br />Transport Company Representative (please print) <br />ransport Company Representative signature <br />Date: <br />Drilling Fluid DisposalJDesiption: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br />Rick Mitchell, Owner <br />