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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: t4.I1-11 <br /> ttitAK Pt i'1440iirkrr L.G 41155 5 Marl ST Sfc" t 0 AVZorA Cp tam, <br /> Name of Drilling Company, City, State,Zip (please print) <br /> gi t S AIT -1 Ee I l tv.J ,1 S, CotsTy,,et,t,oRAco <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> ATTR. fituo 4 rw IP -140 Clch4uftfi To 4 ..00A¢6ori5 <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 /> ..a.aaivu <br /> Commission. <br /> eot4Ro I,um <br /> Authorized Drilling 7. , Representative (please print) <br /> /111 <br /> Date: ti"I "n <br /> Authorized Drillingli/�� Com.any Representative signature <br /> krr VIl Etp 5rgsba5 <br /> Name of Transport Company disposing of above material (please print) <br /> Transport Company Representative (please print) <br /> (0t�1 ft1 Date: -11-11 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits,Bennett, CO 80102 <br /> 2(Z <br /> w. t-s <br /> Rick Mitchell, Owner <br />