Laserfiche WebLink
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: �I23,It,,blZA`Ib 110 <br /> 3 1,pPDs <br /> I�rr►�oE p,�+��or�K,ll[, (�1�'S MA+� 5r, S�.ZI� CD $oDlb <br /> Name of Drilling Company, City, State,Zip (please print) <br /> art V,1 + 6 w-i L3 SWIW 310 Tqs,QS,0 ,�Opma_�o�►tn' �wl�oo <br /> Well Location/Job Site of Drilling Fluid (please print) <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 /> Auth iz d Dr' mg Wmpany Representative (please print) <br /> Date: <br /> Aut orized Dril in Company Representative signature <br /> PiP 61u,'6P S40ncf:s <br /> Name of Transport Company disposing of above material (please print) <br /> Transport Company Representative (please print) <br /> Date: 6- <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits,Bennett,CO 80102 <br /> Rick Mitchell, Owner <br />