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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 />as required by the Colorado Division of Reclamation Mining and Safety <br />5-n-15 <br />Renegade Oil & Gas Company <br />6155 S Main St Ste 210 <br />Aurora, CO 80016 <br />Name of Drilling Company, City, State, Zip (please print) <br />5zittf 6i impo 1.33 Svasoa 33 .j65, � , Aroma (0frAY, %apo <br />Well Location/Job Site of Drilling Fluid (please print) <br />J Rbugv Dou-04 - No baa K& -ro kizoWR0o is <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 />Evvitm 446 <br />Authorized Drilling Com <br />y Reps sentative (please print) <br />Authorized Drilling Company <br />resentative signature <br />Date: 5415'l� <br />Nft 61ORRvtES <br />Name of Transport Company disposing of above material (please print) <br />Transport Company Representative (please print) <br />Transport Company Representative signature <br />Date: 5-73 a 17 <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br />Rick Mitchell, Owner <br />