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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 n <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: -i - %A - li <br />Z1~(AX � 44K MY, LV, 6155 S P0445T �rr-Zlo AUZW CO UPIL <br />Name of Drilling Company, City, State, Zip (please print) <br />L7I�v �fATy I ICA <br />IZ ,-i-55 , ¢L'�411 �FblioE �ou�7Y, l btdW�a <br />Well Location/Job Site of Drilling Fluid (please print) <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 />Gowlp i Aq1~ <br />Authorized Drilling C p Representative (please print) <br />Date: <br />Authorized Drilling Compdiy Representative signature <br />k1f al.Fisw . jfVIzi5 <br />Name of Transport Company disposing of above material (please print) <br />`ram wpwW <br />Transport Company Representative (please print) <br />Date: <br />Transport Company Representative signature <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br />Rickitcheil, Owner <br />