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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: 2T IA <br /> ` ii.,ADE Olt.e-646CnKra{Y, I.u, 6)155 5 NIMaST Gr2to Avzom Co Boal, <br /> Name of Drilling Company, City, State, Zip (please print) <br /> girtpSoxr SZ-I Scala.,'62 ,-r"S,¢WJ 40144De Carr(,ebizo <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> \p'ifiR.456171 414,44 tiv 1p - 140 Exf oSuRfi Tv 6DQDCAQbOr45 <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 /> EOWALV 10445 <br /> Authorized Drilling om any Representative (please print) <br /> (IL <br /> Date: <br /> Authorized Drilling Co pany Representative signature <br /> cif OnFiEW 5031zi5 <br /> Name of Transport Company disposing of above material (please print) , <br /> TMWE <br /> Transport Company Representative (please print) <br /> (C14 Date: 7-71-11 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br /> ,7"(0,-; - /, ‘,/- . 7`4,-/L <br /> Rick Mitchell, Owner <br />