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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: IZ-15-lte <br /> �F�A� d�►,•l�►sCra�+vnr, t.1.L (o15S511a,�St,5�1�n �� CA$oolc� <br /> Name of Drilling Company, City, State, Zip (please print) <br /> 5TXTE 1(P-I& 560oA Its ,i 25 �WQ,NA'+s l vo i , CDLVMa <br /> Well Location/Job Site of Drilling Fluid (please print) <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 /> EVWW Ip4g <br /> L <br /> orized Drillin_dMg Co a y Representative (please print) <br /> - �•lb <br /> Date: �Z 1 <br /> Authorized Drilling Com any Representative signature <br /> Pur 0IL6&LV �X9_110ES <br /> Name of Transport Company disposing of above material (please print) <br /> Transport Company Representative (please print) <br /> IC'Uk � 1t ' _ Date: IZ-1S-Ito <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br /> Rick Mitchell, Owner <br />