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Mitchell Sand and Gravel, <br />48580 Hwy 36 - P.O. Bos 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: � -ZI • )I <br />Renegade Oil & Gas Company <br />6155 S Main St Ste 210 <br />Aurora, CO 800I6 <br />Name of Drilling Company, City, State, Gip (please print) <br />'JURV s 6taroot, I--% 5Scr.o3 33 -rr s.wa . 40PACr: (pw4y, (-L=vo <br />Well Location/Job Site of Drilling Fluid (please print) <br />WAU &%D 1 j 4.14 &Iv — No btPa�& -ro WwOvig <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 />EWAV w6kk-, <br />Authorized Drillin Comp y R resentative (please print) <br />r� _ <br />Date: <br />Authorized Drilling Company epresentative signature <br />H►1 bltrniow SeKVILEg <br />Name of Transport Company disposing of above material (please print) <br />76-M fly <br />Transport Company Representative (please print) <br />Transport Company Representative signature <br />Date: b qn `l7 <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett CO 80IO2 <br />4RjckMitchell, wner <br />