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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: �I3-1fi <br /> REriOOVE 0), '-6A4W4'P(l.w b)s55h�sr 5a7Z Avg, Ca V0116 <br /> Name of Drilling Company, City, State,Zip (please print) <br /> �►ce►�s$+�l Sbctiea l�;T7,s ,iZ6bN Co�Y,�t,d4►Do <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> 1 ACEst Df-%V }�,c,u.11441 ru»D - o E ff"--W r IWOCAMjs <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 C n Representative (please print) <br /> Date: ly' -16 <br /> Authorized Drilling Com ny Representative signature <br /> f �i AMELp Smvuf5 <br /> Name of Transport Company disposing of above material (please print) <br /> Transport Company Representative (please print) <br /> :I&V L.l��'J� Date: <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett CO 80102 <br /> Rick Mitchell, Owner <br />