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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: i--1;.-11 <br /> %4EA1wE On.•GA6Cor14,+Y, UG (,i5s5&piSr,5-112.t0 AU DM CD Souk, <br /> Name of Drilling Company, City, State, Zip (please print) <br /> jalE 1(p•tL 5G-Ii ort IL 1T5 ,"(iz ),Nsiets Cowl', Coiz*r a <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> 1).C,1EK&5617 ltUI4( FL-W9 - o 6417a51.0.70 Artocaato4.5 <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 /> Cioln fission. <br /> Evul>Pev 1 <br /> Authorized%TO <br /> rilling C a Representative (please print) <br /> c� Date: 1 .7c-.1---7 <br /> Authorized Drilling Comp,4 y Representative signature <br /> NT?>• 0t ►tip 6E0 tcES <br /> Name of Transport Company disposing of above material (please print) <br /> Transport Company Representative (please print) <br /> Nt 0 0 0 Date: )"7-. -11 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br /> ' F 7 <br /> Rick Mitchell, Owner <br />