Laserfiche WebLink
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: 1-5-11 <br />Renegade Oil & Gas Company <br />6155 S Main St Ste 210 <br />Aurora, CO 80016 <br />Name of Drilling Company, City, State, Zip (please print) <br />51W5 * Gummo 7.45 'xCfj w �1J , i 7tJ 7,&4%4 4+ 0bi GueXY . lY baO <br />Well Location/Job Site of Drilling Fluid (please print) <br />4a bwD D. W*a& �I_Vty - �o &FA50RE `rV h YVWgM0N5 <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 Drillin omp esentative (please print) <br />c1 Date: <br />Authorized E611ing Company WdPresentative signature <br />0 daisy SEl VI,5 <br />Name of Transport Company disposing of above material (please print) <br />Transport Company Representative (please print) <br />r <br />Date: <br />Transport Company Representative signature <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br />Rick Mitchell, Owner <br />