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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: \ -Tv 17 <br /> 6gGiog DlL+bws CDHP Y,ILL 10)655 Y1 it 6r . tib QuaofzA CD $066 <br /> Name of Drilling Company, City, State, Zip (please print) <br /> 4 1 KE(46 • 4131 .mor►11,TZS, UPI W , 6Am Cww,rc i,(tomb <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> 1,,iYii L7p6ev\-)14wm41"un! - 1vo GX9o900-1-0 'ln.004431/4 <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 /> �DWAIW 114.6`E <br /> Authorized Drilling Con Representative (please print) <br /> /I <br /> Date: <br /> I '71--11 <br /> Authorized Drilling Comp y Representative signature <br /> ikli D1 i&7 JE ►,(a. <br /> Name of Transport` Company disposing of above material (please print) <br /> IoM YV�u-MA,I <br /> Transport Company Representative (please print) <br /> I-- l <br /> -Al / Date: 1.7-t) l l <br /> Transport Company Representative signature <br /> Drilling Fluid DisposaVDestination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br /> _712:7IKr::'' -/-Z4L- <br /> Rick rtchell, Owner <br />