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RECEIVED <br />FEB 16 2018 <br />Mitchell Sand and Gravel <br />DIVISION OF RECLAMATIM .18380 flwy 36 - P.O. Bos 10, Bennett, CO 80102 <br />MINING MDSAFETy 303-6444102 303-870-1260 cell <br />— A disabled American veteran owned company -- <br />Authorization Form for Disposal of Water Bused Bentonitic Drilling Fluids <br />From Water Well Drilling Only <br />As required by the Colorado Division of Reclamation Mining and Safety <br />Date: 6 Az <br />� <br />('GV j -r C <br />' . o dxtAc -s /3w �> e <br />Name of Drilling Company, City, State, Zip (please print) <br />�R �S 6 of� C-© <br />Well Location/Job Site of Drilling Fluid (please print) <br />'J4- /Vp/ G/c _• <br />of Material/Fluid (please print) <br />Drilling Company guarantees that all material to be disposed of, is both non -hazardous <br />and non -harm Cul 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 />Authorized Drilling Company Representative (please print) <br />_ Date: <br />uthor6 filling Company Representative signature <br />Name of Transport Company disposing of above material (please print) <br />.So�1 M �T' �� 1 <br />Transport Company Representative (please print) <br />Date: (v t 3 t+ <br />Transpot.tompany Represengative signature <br />Drilling Fluid Disposal,'Destinatipp: <br />Rick Mitchell, Owner <br />C-0. S 06.,71 <br />