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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 /> 5 MN, 5 i SEE 710 k%M Co UPI(; <br /> Name of Drilling Company, City, State,Zip (please print) <br /> DIap rATE-61-) .fit, II&g1 z ;TI65,Djh) FA?AA Kl+Otr4y,1bl jPto <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> �p'fi:R-�P�,9 LR1W�34 rW lD -�0�'1c�pyV�To II`fDQ.OGs¢>SO�S <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 /> Eowwp Iow rx <br /> Authorized Drilling C mpany Representative (please print) <br /> Date: I0 A•1ln <br /> Authorized Drilling Corwpany <br /> 'Representative signature <br /> Aof o �Lile .�1kE5 <br /> Name of Transport Company disposing of above material (please print) <br /> -r �r/W� <br /> Transport Company Representative (please print) <br /> —7,— ,, Date: lo'l`i'►` <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett CO 80102 <br /> Rick Mitchel , Owner <br />