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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 /> From Water Well Drilling Only <br /> As required by the Colorado Division of Reclamation Mining and Safety <br /> Date: l <br /> Name of Drilling Company, City, State, Zip (please print) <br /> 5�,� Z4'1;�a- — Az cjy',5:Q CO.- <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> Name/type of Material/Fluid ( lease 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 Regulations <br /> and State of Colorado Regulations. If adverse weather(rain,snow),please Contact me <br /> first: tracking mud from the pit onto Highway 36 is not permitted by CDOT. <br /> ;J e4 �rC.•, , ecl ,, e/ <br /> Authorized Drilling Company Representative (please print) <br /> Date: <br /> uthorize Drilling Company Representative signature <br /> /a i� or��G le S <br /> Name of Transport Company disposing of above material (please print) <br /> Transport Company Representative (please print) <br /> Date: <br /> ransp rt Company Representative signature <br /> Drilling Fluid Disposal/De ' ation: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br /> g <br /> Rick Mitchell, Owner <br />