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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: -1.1' • 1`1 <br />Renegade Oil & Gas Company <br />6155 S Main St Ste 2 to <br />Aurora, CO 80016 <br />Name of Drilling Company, City, State, Zip (please print) <br />5ra* * Cbworgo z3S Sx<tbi'53,T55,R&4W , <br />Well Location/Job Site of Drilling Fluid (please print) <br />W7EK bK'16p Duxs6 fG.ULD • �o Cx?a5b9 To 4ktA¢ A5 <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 />6py ) wwc <br />Authorized Drilling Co Representative (please print) <br />:Z/" Date: <br />Authorized Drilling Compa6 Representative signature <br />Name of Transport Company disposing of above material (please print) <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 />Rick Mitchell, Owner <br />