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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: U.%_11 <br />&AUAX �,i-6Att6ANAY, LLL j 15G S PPW5T SEE -110 kftrA cc UPI L' <br />Name of Drilling Company, City, State, Zip (please print) <br />F7�tvS[Ar V 56—.1 iWI311 11,15517MYj 4Aft* I aVoy' �tdu�o <br />Well Location/Job Site of Drilling Fluid (please print) <br />p sL9 Qt%wa4rLv tiv 4 L�cYaS Tv i�Yofz�Ca"ar+s <br />Name/type of Material/FIuid (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 />Authorized illin Com any Representative (please print) <br />Date: <br />Authorized Drilling CAipany Representative signature <br />kif aurIELV6W41d5 <br />Name of Transport Company disposing of above material (please print) <br />-ro+^ Q1~tL*W <br />Transport Company Representative (please print) <br />Date: G •� -1Z <br />Transport Company Representative signature <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80IO2 <br />Rick Mitchell, Owner <br />