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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: V•Z5-11 <br /> 'Lew O►u+‘Cottrot4Y, LLC 6155 5 MPartST Sri2io Aveco Co $o0, <br /> Name of Drilling Company, City, State, Zip (please print) <br /> DI Rw JCAr V-1 5E4)04 ,T55,V J AWAti os Coin,ebt,osiaco <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> W.-Mg-456V a4,44 rW tP - 140 EtcroS S To N4{DROCAilbor45 <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 /> EowPaa ru,J& <br /> Authorized Drilling Co p Representative (please print) <br /> Date: 1'25-11 <br /> Authorized Drilling Compathy Representative signature <br /> kip OijEip 50-3htis <br /> Name of Transport Company disposing of above material (please print) <br /> -CO WettettS <br /> Transport Company Representative (please print) <br /> l 4 �1J1 'C'v`'"/ Date: 1.6-11 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits,Bennett, CO 80102'. <br /> • <br /> Rick Mitchell, Owner <br />