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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: WZ'14'110 <br /> &Y3WE d,L'6A_i(WfMY, U4 61Ss5&$6-r,511t710 ,JWA Co $001t. <br /> Name of Drilling Company, City, State, Zip (please print) <br /> 5TX1E 1("W 561M Ott 1� ,17-5 (►ZW,�va'�s CoutY, CotOWO <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> �aifR c7PsED ata t� �w�v ao 6Ya k'tM7* �JPVoWADAS <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 /> EVWW 1px <br /> Authorized Drilling Co a y Representative (please print) <br /> Date: IZ—lei-1 b <br /> Authorized Drilling ComliAy Representative signature <br /> NIT C' o6kp `JEa ICUP <br /> Name of Transport Company disposing of above material (please print) <br /> Transport Company Representative (please print) <br /> Date: 1�'t`1•lle <br /> Transport Company Representative signature <br /> Drilling Fluid DisposaUDestination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br /> G <br /> Rick Mitchell, Owner <br />