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Mitchell Sand and Gravel, <br />48580 Hwy 36 - P.O. Bos 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: L '7P 't_' <br />Renegade Oil & Gas Company <br />6155 S Main St Ste 210 <br />Aurora, CO 80016 <br />Name of Drilling Company, City, State, Lip (please print) <br />cFrrobt�vd 1.33 S�cl'ias'6.65,R�.�u+of toval�, L�mpo <br />Well Location/Job Site of Drilling Fluid (please print) <br />�Xiu &9tti'DA%U# i Ruth - !`qtr W` bbx& -ro t' CARO'Jb <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 />EWAVV <br />Authorized Drilling Com ,y Rfresentative (please print) <br />Date: ("7-°'17 <br />Authorized Drilling Company representative signature <br />H► t �1>l+W SjZV�cC� <br />Name of Transport Company disposing of above material (please print) <br />7��1UW44 <br />Transport Company Representative (please print) <br />__;_1 <br />Date: 7.b 11 <br />Transport Company Representative signature <br />Drilling Fluid DisposaVDestinatio%n: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br />"/cam <br />Rick Mitc el , Owner <br />