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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: Z--n-ti <br /> .VOlE.0 DtL}6mCottrAr4Y, LLG 10155 S QST S r 21 O AveorA Co $Qpl(, <br /> Name of Drilling Company, City, State, Zip (please print) <br /> glexP6ie SZ-1 5ECriet432 ,-rjs,¢t,4 J NeAliDE. Cotg►Y,e,tirAco <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> Pigg-456P UW-IA rW IP ^ 140 I.'KioS To N`{DROCARZCrJS <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 /> Eowvw 104\15 <br /> Authorized Drilling Co any epresentative (please print) <br /> / 14,, Date: 7-1.1.11 <br /> Authorized Drilling Compaify Representative signature <br /> O ISE W.SSI 1t65 <br /> Name of Transport Company disposing of above material (please print) <br /> TM Wei <br /> Transport Company Representative (please print) <br /> Date: 2-21.11 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br /> 7 <br /> 7"2'.;* L_Rick Mitchell, Owner <br />