Laserfiche WebLink
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 />From Water Well Drilling Only <br />As required by the Colorado Division of Reclamation Mining and Safety <br />440/15 <br />G op <br />jrl %b l 8%/I5 <br />v e 5 13002 CR J8 f'r LctPrz2, CD. g©6�� <br />1'qame of Drilling Company, City, State, Zip (please print) <br />AiipAc3,e Le 1/ #,4 C 0 oiNu i2.. 14i E <br />Well Location/Job Site of Drilling Fluid (please print) <br />12e,pr„ [ �� / i 11,---/ 4,c/ <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 />RSC-✓ <br />Authorized Drilling Company Representative (please print) <br />'e--'.- <br />orized Dril ing Company Representative signature <br />MF_ <br />Date: h <br />Name of Transport Company disposing of above material (please print) <br />Transport Company Representative (please print) <br />Date: <br />Transport Company Representative signature <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br />,t4-41( <br />Rick Mitchell, Owner <br />