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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: -1-16 <br /> '&rtUAX�L-'44oKPa4Y, I.LG ( I 5 6 5fAA4Si �rc.Zlo kCorA Co UP)1, <br /> Name of Drilling Company, City, State, Zip (please print) <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> �p'f1;K. �LtWrl4 rW►fl -�0�'1cQo5�Tv F�{DQD!.a¢Eor�S <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 /> Gov IAg5 <br /> Authorized Drilling Co y epresentative (please print) <br /> �4 Date: ll Z 1L <br /> Authorized Drilling Compan epresentative signature <br /> �� OLYIEW�IcE5 <br /> Name of Transport Company disposing of above material (please print) <br /> �J <br /> Transport Company Representative (please print) <br /> Date: ll•Z I� <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br /> Rick Mitchell, Owner <br />