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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: lto'1(0 <br /> '&C(AOE �t.'44*rogy LV, 6155 S IAPwST SrEZ10 korA Co UP)to <br /> Name of Drilling Company, City, State,Zip (please print) <br /> ZIVw rATE_�7-1 56c'icvJ�7 ,`r5S,DJW l MVAIIRK CarnY,C40rAco <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> I pMI &W UR%W'44 rwtv - k c-"Xyo5�Tv(DQOCAaboryS <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 /> Gotow Authorized.a mp y Representative (please print) <br /> / Date: <br /> Authorized Drilling Co any Representative signature <br /> A1f aLFiEw 6041ti5 <br /> Name of Transport Company disposing of above material (please print) <br /> o41 '4014111alw ti <br /> Transport Company Representat a (please pri <br /> G/I ) <br /> Date: 1�'IL•i� <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br /> Rick Mitchell, Owner <br />