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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: <br />t er1EGAO /X.5 (.0104•Pi U..t• 5 ?'1at,J 5i Sr 7,]t, i -vera Cu bow, <br />Name of Drilling Company, City, State, Zip (please print) <br />,>t-gmor rtwtuwo .C•iriaa 7.3 ,T5S ?691A) Cuu ar; , Co;Draoc� <br />Well Location/Job Site of Drilling Fluid (please print) <br />[n1ATO r.1F•SeD u,u, ii.v,. JD l �c e=f Pr s Tc N vu41.1cnvB01•;s <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 alt applicable Federal and State <br />of Colorado Regulations, including Rule 907 of the Colorado Oil and Gas Conservation <br />Commission. <br />Authorized Dsepresentative (please print) <br />Authorized Drilling Com ny Representative signature <br />r ' ('ILFtiw J vtC`s <br />Date: ZZ • i5• <br />Name of Transport Company disposing of above material (please print) <br />Transport Company Representative (please print) <br />Date: 11 2J- i'; <br />Transport Company Representative signature <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br />Rick Mitchell, Owner <br />