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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: 7-15-I1 <br /> ttc.GADE OIu+.6gCCNr ,4'r L1L 6155 GIANAST Co Upii, <br /> Name of Drilling Company, City, State,Zip (please print) <br /> gi wS A - fer,eel X52 ,155,171A1nl Qp.APbNCE CO(r ,Cetdaaco <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> p - 04114a41-;IP -40 E 'o5uRTiTo N`fPQOCARbor15 <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 /> &LAPP 11414: <br /> Authorized Drilling .mp. y Representative (please print) <br /> ( 4. , sz Date.: 7.13•Il <br /> Authorized Drilling Co .any Representative signature <br /> �-f OLFlEa2 6ggihig5 <br /> Name of Transport Company disposing of above material (please print) <br /> TM [,NEw <br /> Transport Company Representative (please print) <br /> 0,0 Ititf2 Date: 2. )3-11 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination:Mitchell Sand and Gravel Pits,Bennett,CO 80102 <br /> R <br /> / Rick Mitchell, Owner <br />