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Mitchell Sand and Gravel, <br />48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 <br />303-644-4102 303-8704260 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; `l -11-11 <br />6175 5 014ST SmZto keta Co $dpli, <br />Name of Drilling Company, City, State, Zip (please print) <br />D�/A. MTE- V-1 5Wia4S7 ,-MS,VMW %i►NWE Goc,ay.('et�o <br />Well Location/Job Site of Drilling FIuid (please print) <br />Y �Lt W rl4 rW 1 p - 0 �'K�O To �iatfllA�+orsS <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 />Gotowo IAge <br />Authorized Drilli4COany <br />Representative (please print) <br />Authorized Drilling L--. Representative signature <br />k1f OLYISW 64 t1tE5 <br />Date: ~i 11 li <br />Name of Transport Company disposing of above material (please print) <br />Transport Company Representative (please print) <br />_fi <br />Transport Company Representative signature <br />Date: x'11' 11 <br />Drilling Fluid Disposal/Destination; Mitchell Sand and Gravel Pits Bennett CO 80102 <br />� <br />r� Rick Mitchell, Owner <br />