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Mitchell Sand and Gravel, <br />48580 Hwy 36 - P.Q. 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 />lLUAX N-4SC8rMY, UL 6156 S PAPIST SrZID k2tgA COW)(, <br />Name of Drilling Company, City, State, Zip (please print) <br />146%T6 SI -I 5rCi irrl u '-Ms' VmVi UAftK COLI Y , Cb & <br />Well Location/Job Site of Drilling FIuid (please print) <br />M14Z7{WtWrt4 rW ID — i�4 �'1CQ05 TviD1ZbG�1SOrs5 <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 />Gotowp i <br />Authorized Drilling <br />Authorized Drilling <br />Representative (please print) <br />Representative signature <br />Date: i -5 -ll <br />kif 0 Flew 5W1465 <br />Name of Transport Company disposing of above material (please print) <br />-ram �P_I MAN <br />Transport Company Representative (please print) <br />l <br />C4#t Date: <br />Transport Company Representative signature <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett CO 80IO2 <br />Rick Mitchell, Owner <br />