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Mitchell Sand and Gravel, <br />48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 <br />303-64.1-4102 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: i 0 '15 '" <br />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 />`.7tatE p� �b4acr.�a 'i' 3'S 56cr, ,,t'i3,' S , RIo�iW , �1%paj 66,,vy . 6,,aa <br />Well Location/Job Site of Drilling Fluid (please print) <br />D4uW6 &P - j 0 6?Obeizl: Tv f'�YDRat�8or15 <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 />6D, lawc <br />Authorized Drilling Co 2anypresentative (please print) <br />t'i/= Date: W15-11 <br />Authorized Drilling Comp Representative signature <br />Name of Transport Company disposing of above material (please print) <br />—Tam l two <br />Transport Company Representative (please print) <br />Date: k0-75.11 <br />Transport Company Representative signature <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br />Rick Mitche] ,Owner <br />