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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: 11-3.1� <br /> 'LuA E PA#4ST �1C710 kVorACD UOlfi <br /> Name of Drilling Company, City, State,Zip (please print) <br /> gi0SMn SZ-I 'Drajapt U ,`f55,"* WNAo& Cmm,CbLwpo <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 /> Gowwv I,�,J� <br /> Authorized Drillin Co pany Representative (please print) <br /> f Date: <br /> Authorize Drilling Comp Representative signature <br /> Name of Transport Company disposing of above material (please print) <br /> Transport Company Representative (please print) <br /> ulaxtu�" Date: <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br /> Rick Mitch 1, Owner <br />