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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 />//b '- <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: ' 1.1 1 <br />+laf:e e;4;4 i.�_l. 4�'.. 1Cir40 (-%t <br />Name of Drilling Company, City, State, Zip (please print) <br />r • <br />1 <br />ZFL., iii.�L...1� )�) ] i rl, IL.• <br />Well Location/Job Site of Drilling Fluid (please print) <br />:1r/L' (� �`L l/K `Iws K. „ Y i . J..1 .�.. 4. .a., ;' l i•j, �jy, ��t 1:0 <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 r'lling mean epresentative (please print) <br />Authorized Drilling Col p. ny Representative signature <br />Al; (1t1rtiL <br />Date: 1 11 1 <br />Name of Transport Company disposing of above material (please print) <br />Y <br />Transport Company Representative (please print) <br />an 1..)-14-e-6; ._--- <br />Transport Company' Representative signature <br />Date: % -1 r-%_ <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br />2 <br />Rick Mitchell, Owner <br />