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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: 1'tti'L3 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 />LJTRtirVF Guarav Z•3� Ti ert'S'�,"�5S,R[oW4S ., pf�ita� (� GLorcet! <br />Well Location/Job Site of Drilling Fluid (please print) <br />wga bmv DwuwG 6w - �o &PaSbtzl TV PYVW_ a 0'15 <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 Drill* Com y epresentative (please print) <br />�' " Date: � • 11.1 <br />Authorized Drilling Comp y Representative signature <br />Quf1ew 561tvW'5 <br />Name of Transport Company disposing of above material (please print) <br />hlwm <br />Transport Company Representative (please print) <br />Date: 1-11'0 <br />Transport Company Representative signature <br />Drilling Fluid Disposat/Destination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br />r -14 <br />Rick Mitchell, Owner <br />