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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: 6.7-1-1l <br />Renegade Oil & Gas Company <br />6155 S Main St Ste 2I0 <br />Aurora, CO 80016 <br />Name of Drilling Company, City, State, Zip (please print) <br />.11 'r �jj40R 35 , 6A �5, 1 :)5, ,&qW - 6%pal G.xy. , & -boa <br />Well Location/Job Site of Drilling Fluid (please print) <br />r, bAsdv'4u.WG �.vvv - �o EnP45w Ta �ymuaw,45 <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 />A&V <br />Authorized Drill' Com epresentative (please print) <br />Authorized Drilling Compan epresentative signature <br />Date: G'�1' 1� <br />0 dal" SERvu.1S <br />Name of Transport Company disposing of above material (please print) <br />-ToM Iii wm <br />Transport Company Representative (please print) <br />_ Date: <br />Transport Company Representative signature <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br />s <br />Rick Ivlitc ell, wner <br />