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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: ti'11-1-1 <br /> ZAK Ott- gC ttrA4T, LIC, 6156 5 PAPIST 210 t goRA Co $0016 <br /> Name of Drilling Company, City, State,Zip (please print) <br /> glitv6miT,SI-1 Sericol Sz ,T55,¢Lihl Aaawmt . Catrr►Y, `(,etzegio <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> WW1t 414 rwto - 140 e'XroS Tv 14411Dlt.oCA¢6or45 <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 /> EowPav 1 hiGJii <br /> Authorized D illing m Representative (please print) <br /> iti-A,t Date: 9.11.11 <br /> Authorized Drillingli/ G <br /> �� Corn any Representative signature <br /> IV <br /> Name of Transport Company disposing of above material (please print) <br /> TM Wets <br /> Transport Company Representative (please print) <br /> 7 ( t L Date: M'11'11 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination:Mitchell Sand and Gravel Pits,Bennett, CO 80102 <br /> Rick Mitchell, Owner <br />