Laserfiche WebLink
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: ,/,? 5 <br />67/r° <br />• Name of Drilling Company, City, State, Zip (please print) <br />Well Location/Job Site of Drilling Fluid (please print) <br />L% /Co ° <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 mudd from the pit onto Highway 36 is not permitted by CDOT. <br />Scf, - <br />Authorized Drilling Company Representative (please print) <br />orized Drilling Company Representative signature <br />D4 J Ilk Seirvicer <br />Date: 5' 27-%( L <br />Name of Transport Company disposing of above material (please print) <br />Joti yi �K& <br />Transport Company Representative (please print) <br />Transp Company Representative signature <br />Date: 5/6/e <br />Drilling Fluid DisposalfDestination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br />Rick Mitchell, Owner <br />/G/ -a <br />