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Mitchell Sand and Gravel, <br />48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 <br />303-644-41102 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: TIL -Il Renegade Oil & Gas Company <br />6155 S Main St Ste 210 <br />Aurora, CO 800I6 <br />Name of Drilling Company, City, State, Zip (please print) <br />F,cr,W 16 Tas.Rle�14i . A�rnst� GWmt, Cavo <br />Well Location/Job Site of Drilling Fluid (please print) <br />XIU &V_D IDA'U" To YCROCARr &Jh <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 DriIli <br />Authorized Drilling Company <br />ive (please print) <br />presentative signature <br />Date: -1-11—\7 <br />k t Uitr-tap C*KVI&s <br />Name of Transport Company disposing of above material (please print) <br />Transport Company Representative (please print) <br />P& Date: <br />Transport Company Representative signature -` <br />Drilling Fluid DisposaUDestination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br />r <br />1 <br />Rick Mitchell, Owner <br />