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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: {•75-11 <br /> tti.GADE OIL b'644'WKPArtr, loi56 514414Si rltO Avzbot L'0 t(lblfi <br /> Name of Drilling Company, City, State,Zip (please print) <br /> gitv6TATi SZ-1 Stencrl NANIoE C,otrrY,ebtoRaco <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> K- 44a4 rl.V to - (SIO�(foeMt i To 417,DCAR or4S <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 /> EOWNADINLAIES <br /> Authorized Dril ing Co p Representative (please print) <br /> Date.. �{-Z5-11 <br /> Authorized Drilling Co Ganny'Representative signature <br /> AT IT C�lijElp..SKU1ti5 <br /> Name of Transport Company disposing of above material (please print) <br /> Transport Company Re. esentative (please print) <br /> Gtr Date: y Z5-Il <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits,Bennett, CO 80102 <br /> eZ <br /> Rick Mitchell, Owner <br />