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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: -t7- ll <br /> 010-6.440i rotli, L]Ld 10155 5141a5i Gr210 Avaor Co Wit. <br /> Name of Drilling Company, City, State,Zip (please print) <br /> givv r 5Z-I 5(:C;,«,l ,755,VAIN) AgAPbNoc Count',Cotoroo <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> \\\p'fi:axsev 0141104 rW tv - o b' D9.JRS 14xixaciszsoss <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 /> Authorized <br /> Drillin: ' +m y Representative (please print) <br /> � <br /> Date: <br /> Authorized Dril ing Cidmpany Representative signature <br /> kir O ELP 56741ii5 <br /> Name of Transport Company disposing of above material (please print) <br /> TM Wets <br /> Transport Company Representative (please print) <br /> ... Date: Lj'1211 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits,Bennett, CO 80102 <br /> ; <br /> Rick Mitchell, Owner <br />