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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: 10.5-Ib <br /> DtL-4X*tArA4Y, LI(' ( 15'5 5 POW Si SrrZ10 kforA Co UP)(o <br /> Name of Drilling Company, City, State,Zip (please print) <br /> g�wSc>a���-I SbcT'iar�'S2 ,'T55,¢b�1� QR�Pa�orc�ar�Y,�atdd�c <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> R-�P•' ➢�GIWr14 rW I - �0 �OS�R6 Tv NMXAitI r6 <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 /> Eowwo IAgrx <br /> Authorized Drilling Co y presentative (please print) <br /> Date: 10.5-Ito <br /> Authorized rilling Company epresentative signature <br /> ATF D1 iew SEWItis <br /> Name of Transport Company disposing of above material (please print) <br /> �WC4_y, r,\ <br /> Transport Company Representative (please print) <br /> =C�tiL�C Date: �0.6-1(0 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits,Bennett CO 80102 <br /> Rick Mitchell, Owner <br />