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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 -V%-%I <br />Renegade Oil & Gas Company <br />6I55 S Main St Ste 210 <br />Aurora, CO 80016 <br />Name of Drilling Company, City, State, Zip (please print) <br />& L Campo 1.33 ':JEmw I;s.F(Aa, 4a mtar. (p my G�.A+mpc <br />Well Location/Job Site of Drilling Fluid (please print) <br />W� L Fl9tU sc:Irv. vlq — AO ' buO -Vo prG-oW Rria-t3 <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 D1i Cam y R resentative (please print) <br />Authorized Drilling Company <br />bltr-%lap 51 KVIM-S <br />ve signature <br />Date: (9 -_�8- k" <br />Name of Transport Company disposing of above material (please print) <br />-T;,k OCWAPA <br />Transport Company Representative (please print) <br />--/w ma('� Date: <br />Transport Company Representative signature <br />b -Z$ -17 <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br />Rick Mitchell, drvner <br />