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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: (P aq -1l <br />Renegade Oil & Gas Company <br />6155 S Main St Ste 210 <br />Aurora, CO 80016 <br />Name of Drilling Company, City, State, Lip (please print) <br />of &taropo 1.$b `Jscnw 33 TSs.RiA, Ntzatxwcc (PwnY, %avo <br />Well Location/job Site of Drilling Fluid (please print) <br />V DAtwru. t LutJ7 - 40 wl'a k& YoTrY orlaRiw b <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.6IVI, , <br />p� .' <br />Authorized Drilli. �ompqify Ryresentative (please print) <br />VC- Date: L <br />Authorized <br />�Drilling Company representative signature <br />RI UItx�EI.p C*RVtcEs <br />Name of Transport Company disposing of above material (please print) <br />-5� OIrUW44 <br />Transport Company Representative (please print) <br />Date: <br />x.29. t1 <br />Transport Company Representative signature <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br />Rick Mitchell, Owner <br />