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Mitchell Sand and Gravel, <br />48580 Hwy 36 - P.O. Bos 10, Bennett, CO 80102 <br />303-6444102 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.t.n <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 />&6toM�o V6S 51Ek ioo 33. GS,qw. 4WPADE (►tel, (,'Lompo <br />Well Location/Job Site of Drilling Fluid (please print) <br />Name/type of MateriaVFluid (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 Dri1G <br />ve (please print) <br />Date: 6'�_ II <br />Authorized Drilling Compaq y Representative signature <br />kT 61t:5:31rip 56KYIIE!5 <br />Name of Transport Company disposing of above material (please print) <br />7� oswt&l <br />Transport Company Representative (please print) <br />Transport Company Representative signature <br />Date: L"%-11 <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br />Rick Mitchell, Owner <br />