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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: --I&-IL' <br /> 'kAVAK�t�44*tlfMY,Lv, 61y5 S AA0Sz SrrZ10 Co UP)1. <br /> Name of Drilling Company, City, State,Zip (please print) <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> �WIL IVRIWw4 rW ID -k l-xyot�uft To N`� r.p <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 IA46 <br /> Authorized Drilling C y Representative (please print) <br /> Date: IT'S'lb <br /> Authorized Drilling ComGan_y Representative signature <br /> W 1v VtthEtD�hiG�K.iS <br /> Name of Tr-ansspport Company(disposing of above material (please print) <br /> Transport Company Representative (please print) <br /> —7_oW\, WJJ� � Date: 10-5-1b <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett CO 80102 <br /> r <br /> Rick Mitchell, Owner <br />