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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: 11-16 <br /> ,kAEG X pt�1440ttPa{Y,LV, 61y5 5 fAA#4ST SrrEEZ1O k%rA Co UP)(o <br /> Name of Drilling Company, City, State,Zip (please print) <br /> 91KV�MT.V-I 5(-,wq U ,It6,Dqh) WAIT* CV-ST,r,Cook <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> �- �1Wa4 rW IV - I�0�'1cQ05�To N`{DR�CA¢EOrtS <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 /> Authorized Drilling C y Representative (please print) <br /> Date: )D-12.16 <br /> Authorized Drilling Com y Representative signature <br /> W OurIEw'4041 E5 <br /> Name of Transport Company disposing of above material (please print) <br /> ` E— I_ b). /tit cr l d <br /> Transport( �o-m�pany `Representative (please print) <br /> -- � G'Y�L Date: ID-11-I!o <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits,Bennett CO 80102 <br /> Rick Mitchell, Owner <br />