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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: 1.1.1$'11 Renegade Oil & Gas Company <br /> 6155 S Main St Ste 210 <br /> Aurora, CO 80016 <br /> Name of Drilling Company, City, State, Zip ',please print) <br /> bbv 5arl *-1-25 cr oN Z5 ft4, ii~(DVA ,N001g £o u,Jr C'bta tg° <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> WATER V ZZau v 6 F-vtP • 110 tCPaS(RE'VD i-1 YaocsRbcr45 <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 /> 62104 )abs <br /> Authorized Drilling C pany epresentative (please print) <br /> Date: <br /> Authorized Drilling Comp Representative signature <br /> IST OP-VIEW ".RvIttS <br /> Name of Transport Company disposing of above material (please print) <br /> 01::u4,441 <br /> Transport Company Representative (please print) <br /> Date: `1.18'11 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br /> Rick Mitchell, Owner <br />