Laserfiche WebLink
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: h "''D '" <br />15tr1 S(AX 445Ct IA44Y , LV, (175 S M414Si �2210 kVOVA Co UPI to <br />Name of Drilling Company, City, State, Zip (please print) <br />DIV 6i'c. V -i ci ia�1 �aZ ,T55 , ¢b'�YJ FhNo& l dV�►Y , '�t D <br />Well Location/Job Site of Drilling Fluid (please print) <br />�p't�fL 9�tW►l4 rW lfl ~ �b �'K°b�RE Tv il`{DiZbCllit>60�5 <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 />EoWWO 10445 <br />Authorized DDrilling ompa y Representative (please print) <br />.s Date: <br />Authorized Drilling Co any Representative signature <br />k1f aLFIt:Ia _4)rU1c,S <br />Name of Transport Company disposing of above material (please print) <br />TM �e4*w <br />Transport Company Representative (please print) <br />Date: �*3e-11 <br />Transport Company Representative signature <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits BennettCO 80102 <br />g� "-1- -1 1 --, <br />Rick Mitchell, Owner <br />