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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: <br /> �Et1EbADC o14 "GasCw,►Parr l.l,L 1 S5 5 Maw►Sir 5M 410 AVw GD V d 16 <br /> Name of Drilling Company, City, State,Zip (please print) <br /> �,. pwbsl amlla 1 ' ls 'EI04 Coin,fbt Wt' <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> W I►reV Di%V'PG uar44�Lv I D " N 0 Gff"-W �DVOGA &rjs <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 /> Eowwv 1w-c <br /> Authorized Drilling C Representative (please print) <br /> Date: 1�'Z•ll� <br /> Authorized Drilling Com '-y Representative signature <br /> t:'r AI'6ew -�`vut.h <br /> Name of Transport Company disposing of above material (please print) <br /> o jn. �2��Gru a►1✓� <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 /> Rick Mitchell, Owner <br />