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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: 4.1t1-11 <br /> MACAO£Ol .(A5 oiireY, LLG 6155 5 tkiirl ST Gre.210 ?ora Co $b01 <br /> Name of Drilling Company, City, State, Zip (please print) <br /> g,w6 i'3Z-I 5Eer,n,1 U ;n5,itts9h1 A l atio& ezteY,Cotdu>ao <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> P R- Ctu.4 rt.V tP - 14 0 ISc'05g Tv9.0Ca¢E0145 <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 /> eowt.sw1 t44'15 <br /> Authorized Dr'lling C mp Representative (please print) <br /> 1�� Date: y..111- l <br /> Authori ed Drilling�� CorGanny,Representative signature <br /> fr� OuieLp 5 hii5 <br /> Name of Transport Company disposing of above material (please print) . <br /> TM Wei <br /> Transport Company Representative (please print) <br /> Y i ,r ' Date: 4-.0-11 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits,Bennett, CO 80102 <br /> .lc , /^44.t:LI. 7 <br /> l <br /> Rick Mitchell, Owner <br />