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Mitchell Sand and Gravel, <br />48580 Hwy 36 - P.O. Box 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: b -7d -11 <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 printf <br />4+ 1m & 6tampo I- ?s '5 *47, 00 .n" -T ss .ISI a' Nf PAC.G tMV, (.0M90 <br />Well Location/Job Site of Drilling Fluid (please print) <br />Wei R &0_D Dfu*U' ltuiq — No btPa�!U* -ra NTPOtARrJ"4_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 947 of the Colorado Oil and Gas Conservation <br />Commission. <br />Authorized Dril <br />presentative (please print) <br />Date: b. 20 • Il <br />Iling Com <br />presentative signature <br />'R-1 61%rll: p SI Rutr93 <br />Name of Transport Company disposing of above material (please print) <br />Transport Company Representative (please print) <br />�riG�l <br />Transport Company Representative signature <br />Date: 4-7P-11 <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br />Rick Mitchel , Owner <br />