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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: 3 7G 1l <br /> REril:AADE On,•6A5CoPINJY, Lit 6155 Masi r, it Arses CA $00i6 <br /> Name of Drilling Company, City, State, Zip (please print) <br /> jliE11,4 5E6110,1 1o ,T?.5 ,404,6(ouriy, Cot.aca <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> 1)iAjEK Q15ED PZIWA 1 w►v -110 607/hurZETo 1•ViDQo CAato45 <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 /> 1 <br /> Authorized Drilling Comp y R resentative (please print) <br /> Date: 3' : Ft <br /> Authorized Drilling Company epresentative signature <br /> 00,,Fikp 6E17-VICES <br /> Name of Transport Company disposing of above material (please print) <br /> IoM Wit.MP+1 <br /> Transport Company Representative (please print) <br /> Date: 5 'G 1 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br /> Rick Mitchell, Owner <br />