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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 Bentonitie Drilling Fluids <br />as required by the Colorado Division of Reclamation Mining and Safety <br />Date: 9 -76 -11 <br />Renegade Oil & Gas Company <br />6I55 S Main St Ste 210 <br />Aurora, CO 80016 <br />Name of Drilling Company, City, State, Zip (please print) <br />`3sa� o� ��a� x33 �Ttr►�'S3,T5S,K(�IW �f�Na� (��,xY. (A�o� <br />Well Location/Job Site of Drilling Fluid (please print) <br />WNST, 5�56V V4u-V.V'rL.vLV • j Q exPa bgrTV NYaw_X t45 <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 />GVUl�' ptvE <br />Authorized Drill' g Comp y R resentative (please print) <br />Date: <br />Authorized Drilling Company epresentative signature <br />Name of Transport Company disposing of above material (please print) <br />014 Wiau$W <br />Transport Company Representative (please print) <br />Date: <br />Transport Company Representative signature <br />R -y'-11 <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br />r <br />Rick Mitchell, Owner <br />