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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: il••Z•Us <br /> ,&AiXA E '44461irm-y y' ( I 5 PAaST SE210 kOrA Co UP)C, <br /> Name of Drilling Company, City, State,Zip (please print) <br /> gi Rv�Mr-61-1 Ssci onl 3Z ,-T55,QL�rJ QRaPata� �otrttY,vet o <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> �p-tlr�. >t�ctwa4l'wty - �0�'K��SuRiiTv�{DQ,OGt¢SoriS <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 /> Authorized Drilling=presentative (please print) <br /> �'6 Date: <br /> Authorized Drilling Cor p1)4Ty'Representative signature <br /> k1f (/11FIEiD 1tE5 <br /> Name of Transport Company disposing of above material (please print) <br /> e)M ,V�l N'1GY1b✓� <br /> Transport Company Representative (please print) <br /> Date: II•z-110 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits,Bennett CO 80102 <br /> /'� .4 zz '4�r <br /> IV Rick Mitchell, Owner <br />